Questionnaire To Determine Eligibility
ADVERTISEMENT
1
2Questionnaires
State of Hawaii • Department of Education
QUESTIONNAIRE TO DETERMINE ELIGIBILITY
are filed for
HOMELESS CONCERNS OFFICE
MV1
one (1) year for
475 22
Avenue
nd
all students and
Honolulu, Hawaii 96816
seven (7) years
t
McKinney-Vento Homeless Assistance Ac
Telephone: 808-305-9869
for any student
Toll Free: 1-866-927-7095
(MVA)
checking a box
FAX: 808-735-8229
in Section 2.
Student’s Name
School
Section 1:
Student/Parent/Legal Guardian IS NOT in a homeless situation
q
(includes living with friends or family due to personal choice)
(If Section 1 is checked, STOP and complete Parent/Legal Guardian’s signature below; form is complete.)
Section 2:
Student/Parent/Legal Guardian: (Check the box
that applies)
P
q
Lives with friends or family due to economic hardship, such as loss of housing or income
q
Lives on the beach, at a campground, in a park, or in a hotel
q
Lives in a tent, car, bus or other non-permanent structure
q
Lives in a domestic violence shelter
q
Lives in an emergency or transitional shelter (Please circle, or write in name if not listed.)
q
Manaolana, Kuapo, Kauai Economic Opportunity Shelter, Other:
Kauai:
q
Hawaii: Kihei Pua, Beyond Shelter, Na Kahua Hale of Ulu Wini-Kaloko Transitional, Other:
q
Family Life Center (Hoolanani), Ka Hale A Ke Ola, Ka Hale A Ke Ola Westside, Other:
Maui:
q
Family Promise, Institute for Human Services (IHS). Loliana, Ohana Ola O Kahumana, Maili Land, Next Step,
Oahu:
q
Vancouver House, Onemalu, Onelauena (Hope for a New Beginning), Paiolu Kaiaulu (Waianae Civic Center),
Weinberg Village Waimanalo, Ulu Ke Kukui, Ka Ohu Hou O Manoa, Lighthouse Shelter, Kahi Kolu Ohana
O Waianae, Other:
Has no regular place to stay at night
q
The student is awaiting foster care
q
The student is an unaccompanied youth
q
Parent/Legal Guardian’s Signature
Print Name
Date
When any box in Section 2 above is checked, the student may be eligible to receive MVA services including meals and
transportation to and from school. School personnel will assist the Parent/Legal Guardian or unaccompanied youth to complete
the reverse side of this form and any remaining MVA forms.
This questionnaire is intended to address the McKinney-Vento Act (42 U.S.C. 11434a(2)).
The answers provided help determine appropriate and comparable MVA services.
All collected information will only be used for the purposes of providing educational services pursuant to the
McKinney-Vento Act and is protected by federal and state laws.
RS 16-1399, May 2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial