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: _____________________________________________


  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: (     ) ____________________________________