Homeless/Highly Mobile Google Form
Please complete the following HHM Student Identification Information
Email address *
Student Name *
Your answer
MARSS # *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Grade *
Your answer
Gender *
Race *
District 287 School Name & Address *
District 287 Program Name *
Your answer
School Hours *
If not listed, select "Other" and list the hours.
Effective Homeless Date *
MM
/
DD
/
YYYY
Student's Parent/Guardian/Contact *
Your answer
Relationship to Student *
Your answer
Parent/Guardian/Contact Phone Number *
Your answer
Parent/Guardian Current Address* *
*If Address is an Apartment you must include the apartment number in the address. If apartment number is not provided it will delay transportation being set-up.
Your answer
Current Living Situation *
Temporary Address*(if different from Parent/Guardian address)
*If Address is an Apartment you must include the apartment number in the address. If apartment number is not provided it will delay transportation being set-up.
Your answer
Family/Guardianship Status *
Status of Other Homeless Siblings
Include name, birthdate, grade, 287 program.
Your answer
Does student have an IEP? *
Does student require a 504 accommodation? *
Are you requesting transportation to be set up by the Homeless Liaison? *
Special Transportation Needs
Your answer
Other Comments
Your answer
District 287 School Contact *
Your answer
District 287 School Contact Phone # *
Your answer
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