Instructions for school personnel:

The individual providing enrollment and/or student residency information must be provided the opportunity to complete this
form when:
  •  Either of the homeless identifier questions on the Student Registration Form is answered “yes” and/or
  •  Other information is received that indicates that a student’s residency situation may meet the definition of homelessness
If the student is not accompanied by a parent/guardian, the Caregiver Authorization Form may be used in addition to this form
to request additional information from the individual who is primarily responsible for the student.

Instructions for individual completing this form:
The information you provide will be used to determine if the student is living in transition. These students have unique
enrollment requirements and rights and may be eligible to receive additional services. This information will be kept confidential.

* 1. Student First Name

* 2. Student Last Name

* 3. Student Birthdate  

* 4. School

If you answer "yes" to some or all of the questions below, an educational representative may contact you to find out whether your child is eligible for additional educational services?

* 6.  Have you moved to a new town to find work in the last 3 years?

* 7. Did you find work in agriculture or fishing (e.g., field work, canneries, lumbering, dairy work)?

* 8. Is work in agriculture or fishing a major source of income for your family?

* 10. What is your current contact information?

* 11. Please list any alternate phone numbers

* 12. Transportation Request

* 13. By entering my Name, and dating below I am electronically verifying the following:
I am the parent/guardian of the child named above. The information on this form is true and accurate as of the date specified below.

For questions regarding this form please contact Alison Davidson at (850) 561-8370 or (850) 561-8917
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