Students & Families in Transition Question Title * 1. What is the student's current nighttime living arrangement? (please check one) In my own home In a motel/hotel In transitional housing In a shelter (domestic violence shelter, family shelter, children/youth shelter) In a place not designated for ordinary sleeping accommodations (such as car, tent, abandoned building, on the streets, at a campground, or in the park) With more than one family (with relative or non-relative families) in a house or apartment Involuntarily moving from place to place Question Title * 2. Is your current address a temporary living arrangement? Yes No Question Title * 3. Is this living arrangement due to loss of housing, economic hardship or finanical difficulties? Yes No Question Title * 4. Length of time in current temporary living arrangement? 0-3 months 1-3 months 3-6 months 6 months or longer Question Title * 5. Number of relocations in the past year? 0-2 2-4 4 or more Question Title * 6. Are you an unaccompanied youth? (not in physical custody of a parent or guardian) Yes No Question Title * 7. Name of student, gender, school and grade. Question Title * 8. Name of student, gender, school and grade. Question Title * 9. Name of student, gender, school and grade. Question Title * 10. Name of student, gender, school and grade. Question Title * 11. Does the student (or students) have at least 5 tops and bottoms for school? Yes No Question Title * 12. Does the student or (students) have enough school supplies? Yes No Question Title * 13. Does the student (or students) have enough hygiene supplies? Yes No Question Title * 14. Address (please include City and Zip Code) Question Title * 15. We will contact you if your temporary living arrangement qualifies your student(s) for additional educational services. Please provide a telephone number (specify home, cell or work) and a valid email address. Question Title * 16. If you specified a cell phone number as the best way to contact you, is it okay to send text messages? Yes No Question Title * 17. Do we have your permission to share your contact information with other agencies for additional services offered; such as holiday assistance? Yes No Done
