Student Residency Questionnaire Student Residency Questionnaire The information on this form is required to meet the law known as the McKinney-Vento Act 42 U.S.C. 11434a(2), which is also known as Title X, Part C, of the No Child Left Behind Act. The answers you give will help the school determine services the student may be eligible to receive. Name of Student: ___________________________________________________________________________________________________ Last First Middle Building presently enrolled in or building enrolling into: ________________________________________ Gender:

Male

Female

Birth Date: ________/________ /_______ Month Day Year

Grade: _______________

#1 Phone #: ____________________________ #2 Phone #: _____________________________

Current Address: _________________________________________________________ City: _____________________ ZIP: _________ Previous Address: ________________________________________________________ City: _____________________ ZIP: _________ Length of Time at Current Address: ___________________ Last District Attended: _________________________________ Would you like your child to continue attending there?  Yes

Length of Time at Previous Address: ____________________________ Last School Attended: ______________________________________  No

Please check the box that best describes who the student is living with and list the name of the person(s). ❏ Both Parents _______________________________________________________________________________________________ ❏ Single Parent (Father/Mother) _________________________________________________________________________________ ❏ Grandparent (s) (Grandfather or Grandmother) ____________________________________________________________________ ❏ One Parent & Another Adult

_________________________________________________________________________________

❏ Legal Guardian(s) Granted by Court _____________________________________________________________________________ ❏ Foster Parent(s) _____________________________________________________________________________________________ ❏ Other

____________________________________________________________________________________________

Please provide the following information for brothers and/or sisters of the student living in the home: Name

Grade Level or Age if Not in School

School

INFORMATION PROVIDED ON THIS FORM IS CONFIDENTIAL Revised 10/26/15

District

Other living arrangements -- Do you live in any of the following situations?

A.

Sharing the housing with: Name of person, relationship, and # of people in the home

___________________________

________________________________________________________________________________________________________ ____This is a long-term, cooperative living arrangement to save money or similar reason. ____This is due to recent loss of housing due to economic hardship, or similar reason. (Underline those that apply: loss of job, divorce, domestic violence, eviction, fire, mold, lack of electricity, kicked out by parents/U-Y) Are you working with a Case Worker or Legal Authority at this time? Yes  No If so, list Name and Phone #. Name __________________________________________________________________ Phone: ____________________

B.

Student is living with a caregiver (parent in military and deployed, parent is ill, parent(s) in jail, etc.) Explain: ________________ _________________________________________________________________________________________________________ Name of Caregiver and Relationship: _________________________________________________________________________

C. Living in a motel/hotel, campground or similar setting due to: (check one) ____ Lack of adequate accommodations ____ Convenient living arrangement ____ Waiting for apartment or house to be ready

D. In emergency or transitional shelters such as domestic violence or homeless shelters or transitional housing through a shelter or agency. Name of Organization ______________________________________________________________________

E. In cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings. F. None of the above describes my present living situation. Briefly describe your situation: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ How long do you anticipate living at this location?  1 month  2 months  3-6 months  Rest of School Year Is this student in a temporary foster care placement or awaiting foster care?  Yes

 No

Date Placed: _____________________

❏

We live in our own home or are renting IN THE GRAND BLANC SCHOOL DISTRICT or we have been APPROVED SCHOOL OF CHOICE FROM OUTSIDE THE DISTRICT. I understand that false information provided may subject me to legal penalties for perjury. If called to testify that the information provided here is true and correct, I would be competent to do so. I also understand that the school district may seek to verify that this is true information and if not, the student will be removed from GBCS to enroll in their resident district. ____________________________________________________________________ Signature of Parent/Legal Guardian/Caregiver/Unaccompanied Youth (underline)

____________________________ Date

For School Use Only Family indicates that the following is needed: ❏Transportation

❏ Items available from GISD

❏ Tutoring

❏Other ___________

Staff must review family situation on a regular basis and note outcome. Date: __________________ Outcome: ___________________________________________________________________________________ Date: __________________ Outcome: ___________________________________________________________________________________ Date: __________________ Outcome: ___________________________________________________________________________________ ❏ S = Shelters

❏ D = Doubled-up

❏ U = Unaccompanied Youth

❏ HM = Hotels/Motels

I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act. _______________________________________________________________________

______________________

McKinney-Vento Liaison Signature

Date