STUDENT RESIDENCY
QUESTIONNAIRE
This
document is intended to address
the
McKinney-Vento
Assistance Act.
Your
answers will help determine
documents
necessary to
enroll your child
quickly.
Student:
__________________________ Male or Female:
_________________
Birthday: __________________
Grade: ____________ School: ______________
PLEASE CIRCLE ALL THAT
APPLY
1. 
Do
you and your student live in
a fixed, regular,
adequate nighttime residence?
Yes or No
2. Do
you and the student live
in:
A.
Shelter (other than a home or apartment)
B.
Motel/hotel
C.
Temporarily with another family in
a house, mobile
home, or apartment due to financial
necessity
D.
In a car or
RV
E.
At a campsite
F.
Transitional housing
G.
Other______________________________
3. The student
lives with:
A.
One parent
B.
Two parents
C.
A qualified relative
D.
Friend(s)
E.
An adult that is not the legal
guardian
F.
Alone with no adult(s)
4. I
am:
A.
The parent/legal guardian of
the above-named student
B.
A qualified adult
relative of the above-named
student
(Relationship:
___________________________________________________)
I declare under penalty of perjury
under the laws of this state that the information provided here
is true and correct and of my own personal
knowledge.
Signature:
___________________________________________Date:
_____________
Print Your
Name________________________________________________________
Residence:
____________________________________________________________
Street
City
Zip
Mailing Address:
_______________________________________________________
Street
City
Zip
Telephone:
( )_______________________
Cell: (
)_________________________
