Student Residency Questionnaire

Please complete the following questions regarding the student's housing in order to help determine services the student may be eligible to receive.
(McKinney-Vento Act 42 U.S.C. 11435) The information you provide is confidential. Your child will not be discriminated against based upon the information provided.

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* 1. What is the student's legal first and last name?

First Name:

Last Name:

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* 2. What is the student's date of birth?

Date:

Date

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* 3. What is the student's gender?

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* 4. What school does the student go to?

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* 5. What grade level is your student in?

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* 6. Is the student living with a parent or legal guardian?

Yes

No

If NO, please explain whom the student lives with (name and relationship):