Louisiana Student Residency Questionnaire Form - Louisiana Department Of Education

Louisiana Student Residency Questionnaire Form

(Form Must Be Included In School Enrollment Packet)

Date ______________

District/Parish _______________________________

School Name _______________________________

Student Name ____________________________________________________

SSN/ID# _______________________________________

Male/Female _____________

Date of Birth _____________

Address __________________________________________________

Telephone Number _____________

Last School Attended _________________________________

Current Grade ____________

Parent/Guardian/Adult Caring for Student ___________________________________________

Relationship _____________________

Disclaimer: This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant,

Individuals with Disabilities Education Act (IDEA) and/or Title X, Part C, Federal McKinney-Vento Assistance Act, 42 U.S.C.11435. Eligibility can be determined by completing this

questionnaire. It is illegal to knowingly make false statements on this form. If eligible, students are to be immediately enrolled in accordance with Bulletin 741, section 341.

1.  Yes  No Is the student’s address a temporary living arrangement? (Note: If this is a permanent living arrangement or the

family owns or rents their home, sign under item 9 and submit form to school personnel.)

2.  Yes  No Is the temporary living arrangement due to loss of housing or economic hardship?

3. Where is the student currently living? (Check all that apply)

 In an emergency/transitional shelter.

 Awaiting foster care placement.

 Temporarily with another family because we cannot afford or find affordable housing.

 With an adult that is not a parent or legal guardian, or alone without an adult.

 In a vehicle of any kind, trailer park or campground without running water/electricity, abandoned building or substandard housing.

 Emergency Housing (i.e. FEMA Trailer or FEMA Rental Assistance)

 In a hotel/motel.

 Other specific information __________________________________________________________

4.  Yes  No Does your child have a disability or receive any special education services? (Check One)

5.  Yes  No Does your child exhibit any behaviors that may interfere with his or her academic performance?

6. Would you like assistance with  uniforms  student records  school supplies  transportation other?

____________________

(Describe: _____________________________________________________________________________________________________ )

7.  Yes  No Migrant - Have you moved at any time during the past three (3) years to seek temporary or seasonal work in agriculture

(including poultry processing, dairy, nursery, and timber) or fishing?

8.  Yes  No Does your child have siblings (brothers or sisters)? Note: Use back of page if more space is needed.

Name __________________________

School ___________________________ Grade _____________ DOB _____________

Name __________________________

School ___________________________ Grade _____________ DOB _____________

Name __________________________

School ___________________________ Grade _____________ DOB _____________

9. The undersigned certifies that the information provided above is accurate.

__________________________________________________________________________________________________________________

Print Parent/Guardian Name/Adult Caring for Student

Signature

Date

__________________________________________________________________________________________________________________

(Area Code) Phone number

Street Address

City

State

Zip

School Use Only  Free or Reduced Price Meals Form submitted/signed  Copy Placed in Student’s Cumulative Record

Homeless Liaison Use Only- Check All That Apply

 Sheltered

 Doubled-Up

 Unsheltered/FEMA

 Hotel/Motel

Unaccompanied Youth  Yes  No

 Awaiting Foster Care Placement

__________________________________________________________________________________________________________________

Print School Contact

(Revised 3/2012)

Title

Signature (required)

Date