School Use Only - Administrator's determination of Section A circumstances:
Student Residency Questionnaire Douglas County School: Student's Legal Name: Age:
Date of Birth:
Grade:
Parent(s) / Legal Guardian(s):
Gender: M
F
Phone/Pager:
Address:
City:
State / Zip Code:
This questionnaire is intended to address the McKinney-Vento Act. Your answers will help the administrator determine residency documents necessary for enrollment of this student.
1. Presently, where is the student living? (check one box) Section B
Section A Choices in Section B do not apply
In an Emergency Shelter In a motel, car or campsite With friends or family members due to the loss of housing or financial hardship A student not living with parent or legal guardian Other? Explain:
2. The student lives with: 1 (one) parent
a relative, friend(s) or other adult(s)
2 (two) parents
alone with NO adults
1 parent & another adult
an adult that IS NOT the parent or the legal guardian
Signature(s) of Parent(s) / Legal Guardian(s)
Date:
Signature(s) of Parent(s) / Legal Guardian(s)
Date:
Notes: Section B - If Section B is checked, this form MUST be completed and returned to school personnel. **** Completed form is kept in the student's cum file. **** School Contact who may know of the family's situation:
Student Residency Questionnaire - American Academy
a relative, friend(s) or other adult(s) alone with NO adults an adult that IS NOT the parent or the legal guardian. Douglas County School: Student's Legal Name:.
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