Questionnaire To Determine Eligibility Page 2
ADVERTISEMENT
1
2Section 4. Name of School: ___________________________________________________________________________
Student Name: _______________________________________________
_____Male
_____Female
_ _ _ _ _ _ _ _ _ _
Date of Birth________/________/__________Grade_______
Student ID#
Siblings: (Name, age , school and grade)
Section 5. Student is living with friends or family due to economic hardship such as:
_____Loss of Housing
_____Loss of Income
_____Other:___________________________________________
Address:_____________________________________City:_______________________Telephone:___________________
Section 6. Student is applying for the following:
_____Free/Reduced-Price Meals
_____Transportation to and from school ( when feasible) _____Other:________________
NOTE: Services provided will be comparable to services provided to all other students attending this school.
Section 7. Parent or Legal Guardian, please initial agreement to the following:
_____YES. I understand and agree that the Homeless Concerns Liaison may contact me.
_____I will immediately inform the school administrator in writing if any changes occur to this information.
Signature of Parent or Legal Guardian:___________________Telephone:____________________Date:___________
Section 8. For School Use Only
_____Home School (
school within the geographic area of student’s current residence)
_____School of Origin
(school attended when permanently housed /last school attended)
___ GE
__
_____Other_____________________________________________________
PRINT Name of School Representative:___________________________________Title______________________
Signature of School Representative: ______________________________________Date:_____________________
By signing above, the school representative acknowledges that the parent or legal guardian has been provided with MVA information and a copy of this form.
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)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education