Student Residency Questionaire Template printable pdf download

Fremont Public Schools

Date:__________________

Student Residency Questionnaire

This questionnaire is intended to address the McKinney –Vento Homeless Assistance Act. In order to better meet the needs of our students, we ask

that you complete this form as part of our enrollment process.

Student Name:________________________________________________Grade:_______ Birth Date:_______________ Sp. Ed.: yes or no

Where is the student currently living? Check one.

____ In a an emergency shelter

____ In a camper/trailer

____ With another family or friend – Doubled up

____ In foster care

____ In a motel/hotel

____ Unsheltered

____ None of the above, we rent or own

(If this is the case, you do not need to complete the remainder of this form.)

The student lives with:

____ 1 parent

____ a relative, friend, or another adult

____ 2 parents

____ alone with no adults

____ 1 parent/1 step-parent

____ adult who is not the parent or legal guardian

Parent/Legal Guardian Name: ______________________________________________________________________

Address: ______________________________________

City:___________________________ ZIP: _________

Phone #’s :____________________

_____________________

______________________

Or: Non-Parent/Legal Guardian student is living with: _________________________________________________

Address: ______________________________________

City:___________________________ ZIP: _________

Phone #’s :____________________

_____________________

______________________

Siblings:

Name:

____________________________________ Grade:_______

Birth Date:_____________ Sp. Ed.: yes or no

____________________________________ Grade:_______

Birth Date:_____________ Sp. Ed.: yes or no

____________________________________ Grade:_______

Birth Date:_____________ Sp. Ed.: yes or no

____________________________________ Grade:_______

Birth Date:_____________ Sp. Ed.: yes or no

SCHOOL USE ONLY

The student is homeless according to the McKinney-Vento Homeless Assistance Act:

Yes ______ No _______

If YES, the following enrollment requirements are waived under the McKinney-Vento Homeless Assistance Act:

____ proof of residency

____ supervision of parental/legal guardian

____ proof of immunizations (attendance may be delayed until proof is produced or first round of shots is administered)

____ proof of birth record

____ student records and transcripts

Staff Signature/Title:________________________________________________________ Date:________________

Student Residency Questionaire Template

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