Questionnaire To Determine Eligibility

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QUESTIONNAIRE
MV1
State of Hawaii
Schools
MV-1
are required
Department of Education
TO DETERMINE ELIGIBILITY
to keep a
HOMELESS CONCERNS OFFICE
chronological file
475 22
Avenue Room 126
nd
McKinney-Vento Homeless Assistance Improvements Act
of completed
Honolulu, Hawaii 96816
Questionnaires
Telephone:
808- 305-9869
(“MVA”)
for each school
Toll Free: 1-866-927-7095
year.
FAX:
808-735-8229
STUDENT’S NAME: ___________________________________________ SCHOOL: ____________________________
Section 1. Action Requested: (A copy of this form must be attached to each of the following forms.)
□ Enrollment
□ Geographical Exception*
□ Exit, Release or Transfer
□ Transportation (
ONLY when a box in Section 3 is checked)
Section 2. □ Student / Parent / Legal Guardian IS NOT in a homeless situation
(includes living with friends or family due to personal choice)
If Section 2 is checked, STOP and complete Parent/Legal Guardian signature below; form is complete.
Section 3. Does The Student / Parent / Legal Guardian: (Check the box that applies – you may be eligible for services)
□ Live with friends or family due to economic hardship such as loss of housing or income
□ Live on the beach, at a campground, in a park, or in a hotel
□ Live in a tent, car, bus, or other non-permanent structure
□ Live in a domestic violence shelter: (name) ______________________________________________
□ Live in an emergency or transitional shelter: (Please circle or if your shelter is not listed, please write in the name.)
□ Kaua`i:
Manaolana, Kuapo, other: ___________________
□ Hawai`i:
Kihei Pua, Beyond Shelter, Kaloko Transitional, other: _____________________
□ Maui:
Ho`olanani, Ka Hale A Ke Ola, Ka Hale A Ke Ola - Westside, other: _____________________
□ O`ahu:
Family Promise, Institute for Human Services (IHS), Loliana, Ohana Ola O Kahumana, Maili Land, Next
Step, Vancouver House, Onemalu, Onelauena (Hope for a New Beginning), Pai’olu Kaiaulu (Waianae
Civic Center), Weinberg Village Waimanalo, Ulu Ke Kukui, Ka Ohu Hou o Manoa, Lighthouse
Shelter, Kahi Kolu Ohana Hale O Wai’anae, other: ________________________________________
□ Have no regular place to stay at night
□ The student is awaiting foster care
□ The student is an unaccompanied youth
____________________________
_________________________
______________
Parent/Legal Guardian Signature
Print Name/Contact Phone No.
Date
When any box in Section 3. “Does The Student/Parent/Legal Guardian:” is checked, the student may be eligible to receive MVA
services. School personnel are to assist the parent, legal guardian or unaccompanied youth with the completion of the reverse side of this
form and the McKinney-Vento Act (MVA) School Packet.
___________________________
__________________________
______________
DOE Representative’s Signature
Print Name
Date
Geographical exceptions apply to MVA eligible students ONLY WHEN there is a request to have the student attend a school
other than the student’s school of origin or home school.
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.
MV 1 REV 4/2014
RS 12-1187 (Rev. of RS 11-1075)
MV 1, Rev. 5/2014
RS 14-1885 (Rev. of RS 13-1133)

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