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: (     ) ____________________________________