Homeless Students of Butler County Identification Form
Butler County School System is committed to ensuring that all preK - 12 students experiencing homelessness receive equal educational access as outlined in local, State, and Federal policies. The McKinney-Vento Homeless Assistance Act (42 U.S.C.§11435 et seq) defines homeless children and youth as individuals who lack a fixed, regular and adequate nighttime residence.

This form is intended to assist Butler County School Staff in identifying homeless children and youth enrolled in Butler County School System. All information obtained for this purpose will remain confidential. After submitting this form, contact will be made within one week. Call 334-382-2665 extension 1210 or 1205 for questions and/or concerns. We look forward to serving you!

Select School
Student Last Name
Your answer
Student First Name
Your answer
Grade
An unaccompanied/unattached youth is a student who is not in the physical custody of a parent or guardian; this includes youth who have run away from home, been kicked out of their homes, or been abandoned by parents. Is this student an unaccompanied/unattached youth?
Select the statement that best describes where the student is presently living.
How can the person completing this form best be described?
Name of person completing this form?
Your answer
Please list reliable contact information below (cell number, home number, email, etc.).
Your answer
Comments/Questions
Your answer
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