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TITLE X, PART C

MCKINNEY-VENTO CONFIDENTIAL REFERRAL FORM

Louisiana School District ___________________________________________________________________________________________

Date ____________________

Not In School ___________________

Student _______________________________ (M/F)

Parent/Guardian _______________________

Race _____________

School _________________________________

Age ______________

Grade ______________ Special Ed: Yes _______

No ______

S.S.# or I.D.# ____________________________

D.O.B. _____________________

Phone Number _____________________

Temporary Address ______________________________________

City __________________________ Zip ___________

Referring Person ________________________________________

Position ________________________________________________

Reason for referral: Problems listed below often prevent homeless children and youth from attending school. Please check the areas of

concern which apply to the student identified above.

___ School of origin: Yes  No 

Check all that apply:

___ Student lacks a permanent residence

 Sheltered (1)

___ Student is unable to pay school fees

___ Immunizations are needed

 Doubled-Up (2)

___ Birth certificate is needed

 Unsheltered/FEMA (3)

___ Excessive absences are a problem

 Hotel/Motel (4)

___ Lacks academic records and/or documentation

 Awaiting Foster Care Placement

___ Academic problems indicate a need for tutoring

Unaccompanied Youth: Yes  No 

___ School supplies are needed

 01 – Mortgage Foreclosure

___ Transportation to school is a problem

 02 - Flooding

___ Student/family needs assistance accessing community resources

 03 - Hurricane

___ Behavior indicates a need for mental health counseling

 04 - Tropical Storm

___ School clothes are needed (Sizes:

Shirt _____

Pants ______ Shoes _____

Other _____ )

___ Free lunch form needed

 05 - Tornado

___ Health problems are indicated

 06 - Wildfire or Fire

___ Need Health Insurance (LA CHIP/Medical Card)

 07 – Man-made Disaster (Major)

___ Guardianship is a problem

 99 – Other:

i.e., lack of affordable

___ IDEA (gifted, talented, disabilities) services needed

housing,long-term poverty, Unemployment

or underemployment, lack of affordable,

___ LEP/ESL services needed

health care, mental illness, domestic

___ Migrant services needed

violence, forced eviction, etc.

___ Need SNAP benefits (food stamps)

COMMENTS: ______________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Other children in home:______________________________________________________________________________________________

_______________________________________________________

______________________________________________________

School Personnel Signature

Date

Homeless Liaison’s Signature

Date

*LIAISON’S SIGNATURE INDICATES STUDENT(S) MEET TITLE X, PART C REQUIREMENTS

 Copy sent to District Homeless Liaison

 Copy Placed in Student’s Cumulative Record

(Revised 3/2012)

Title X, Part C Mckinney-Vento Confidential Referral Form - Louisiana Department Of Education

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