Residency (McKinney-Vento) Questionnaire

Residency (McKinney-Vento) Questionnaire

Required by state law.
Name of LEA: John González
Student's name*

First NameMiddle InitialLast Name
Student's date of birth*

MonthDayYear
Student's gender*
Student's primary address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's grade*
ID Number
Student's school*

Head Start/Pre-KWest Street School (K–2)North Street School (3–5)Geneva Middle School (6–8)Geneva High School (9–12)
Phone of Parent/Guardian or Student (for unaccompanied homeless youth)*
Please enter a valid phone number.
The answer you give below will help the district determine what services you or your student may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records, immunization records, or proof of age. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living?*

In a shelterWith another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as “doubled-up”)In a hotel or motelIn a car, park, bus, train, or campsiteIn permanent housingOther
Signature of Parent, Guardian, or Student (for unaccompanied homeless youth)*

Clear
Name of Parent, Guardian, or Student (for unaccompanied homeless youth)*

First NameLast Name
Today's date*

MonthDayYear
For office use only
Signature of McKinney-Vento Administrator:

Date:
Should be Empty:

Residency (McKinney-Vento) Questionnaire

For office use only