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Enrollment Residency Questionnaire

This form is intended to address the McKinney-Vento Act. Your answers will help determine residency documents and certain needs for the student.

Student First Name*

Answer Required

Student Last Name*

Answer Required

Complete EITHER Section A OR Section B:

Section A: Presently, where is the student living? (select one)

Answer Required

Temporarily with more than one family (due to loss of job, loss of housing, etc.)

In a motel, car, or campsite

In a temporary foster care awaiting permanent placement

Alone without parental support (independent living student)

In a shelter

Section B: Choices in Section A do NOT apply

Answer Required

YES

Continue: If you checked an option in Section A, please complete the rest of this form.

STOP: If you checked Section B, you do not need to complete the remainder of this form.

Only complete if you selected an option in Section A:

Student First Name

Answer Required

Student Middle Name

Answer Required

Student Last Name

Answer Required

Date of birth

Answer Required

School

Answer Required

Gender

Answer Required

Male

Female

Parent Guardian

First Name

Answer Required

Last Name

Answer Required

Present Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Phone Number

Number Required

Last School Attended

Answer Required