2017-2018 STUDENT ASSISTANCE QUESTIONNAIRE

All information MUST be completed by parent, school personnel or community liaison.

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* Date:

Date

Date

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* School:

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* Student Name:

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* Date of Birth:

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* HISD ID:

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* Current Address:

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* Grade:

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* Sex:

Male

Female

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* Lives with:

Both Parents

Mother

Father

Legal Guardian

Caretaker/Relative without legal guardianship

Other (please specify)

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* Is the student currently in the conservatorship of the Department of Family & Protective Services (Foster Care)?:

Yes

No

If Yes – name of DFPS Case Manager & Contact information:

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* Was the student previously in the conservatorship of the Department of Family & Protective Services (Foster Care)?:

Yes

No