RESIDENCY QUESTIONNAIRE

The information on this form is required to meet The Education for Homeless Children and Youth (EHCY) program, authorized under Title VII-B of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11431 et seq.), also known as the McKinney-Vento Act. Presenting false records is an offense under 21 Penal Code Section 37.10 and subjects the person to liability for tuition or other costs. Texas Education Code Sec. 25.001 (h).

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* 1. Scholar First Name

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* 2. Scholar Middle Name

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* 3. Scholar Last Name

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* 4. Scholar school ID number ( If ID number not available, please proceed to the next question)

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* 5. Scholar Gender

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* 6. Scholar Date of Birth

Date

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* 7. Campus

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* 8. Grade Level

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* 9. Home Address

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* 10. Phone Number

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* 11. The answer you give below will help the district determine what services your child may be able to receive under the McKinney-Vento Act. Scholars who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Scholars who are protected under the McKinney-Vento Act may also be entitled to other services. Where does the scholar sleep at night? (Please check one box.)

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* 12. Parent/Legal guardian Full Name

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* 13. Do you have additional children enrolled at Uplift?  If yes, proceed to the next page.  If no, please select "NEXT" and the survey will be complete.

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