Questionnaire To Determine Eligibility Page 2
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1
2Section 3:
Name of School
School of Origin
(last school attended or last school child attended with a permanent residence)
Student’s Name
Male
Female
q
q
Date of Birth
/
/
Grade
Siblings:
Name
Age
School
Grade
Section 4: Contact Information
Address
City
Telephone
Emergency Contacts:
Name
Relationship
Telephone
Email
Name
Relationship
Telephone
Email
Section 5: Student is applying for the following:
Free/Reduced-Price Meals
Transportation to and from school
Other
q
q
q
Note: Services will be comparable to those provided to all other students attending this school.
Section 6: Parent/Legal Guardian
I
understand and agree that the Homeless Concerns Liaison may contact me. I will inform the school administrator if any
changes occur concerning this information.
Parent/Legal Guardian’s Signature
Telephone
Date
Section 7: For School Use Only
_ _ _ _ _ _ _ _ _ _
Student ID #
Student Enrolled As:
Home School (school within the geographic area of student’s current residence)
q
School of Origin (school attended when permanently housed/last school attended)
q
Geographic Exception (GE)
q
Other
q
PRINT Name of School Administrator
Title
Signature of School Administrator
Date
By signing above, the school representative acknowledges that the parent/legal guardian has been provided with MVA
information and a copy of this form.
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