Housing Information Form

The McKinney-Vento Act is a federal law that ensures the right of students to go to school even when they are homeless or don’t have a permanent address. If you feel that the student will qualify, please fill out the following form.

This form is voluntary and distributed to all students admitted into the full-time program.

Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act.

Student First Name

Student Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Student's current Grade Level

Student's Date of Birth

Address (if applicable)

City

State

Zip code

The address above is

TemporaryPermanent

Please choose which of the following situations the student currently resides in (you can choose more than one)

House or apartment with parent or guardianMotel, car, or campsiteShelter or other temporary housingWith friends or family members (other than or in addition to parent/guardian)

If you are living in shared housing, please check all of the following reasons that apply

Are you a student under the age of 18 and living apart from your parents or guardians?

YesNo

Housing and Educational Rights:

Students without fixed, regular, and adequate nighttime residences have the following rights:

Immediate enrollment in the local public school they last attended or the local public school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations;
Transportation to the school of origin for the regular school day (not applicable at VLACS/in a remote setting).
Access to free meals, Title I and other educational programs, and transportation to extra-curricular activities to the same extent that it is offered to other students (not applicable at VLACS/in a remote setting).

By signing below, I acknowledge that I have received and understand the above rights.

Digital/Electronic Signature of Parent/Guardian/Unattached Youth

Date of Signature

*Office use only*
McKinney-Vento Liaison; Please sign & date below: