Morgan County Schools
McKinney Vento Application
Honi Smith, Homeless Liaison
Student Residency Questionnaire
This questionnaire is intended for identification purposes for students who are in transition as required by the McKinney-Vento Act, Title IX, Part A of the Every Student Succeeds Act of 2015 (ESSA) Residency information is imperative to determining the services the student may be eligible to receive. All information in this questionnaire is required.
Complete this questionnaire and return to Kristy Anders, Federal Programs Department Secretary. Email: keanders@morgank12.org
Current, primary nighttime residence: (check one)
□ Shelter, transitional housing, awaiting foster care
□ Doubled-up (e.g., temporarily living with another family)
□ Unsheltered (e.g., cars, parks, campgrounds, temporary trailer, or abandoned buildings)
□ Hotels / Motels (Names:____________________________________)
□ Other (be specific) ________________________________________
The student lives with: (check one)
□ 1 parent
□ 2 parents
□ 1 parent & another adult
□ A relative, friend(s) or older adult(s)
□ Alone with no adult
□ An adult that is not the parent or legal guardian
School: ___________ Homeroom Teacher: _____________ Grade: ___
Name of Student:___________________________________________
Last, First Middle
Male:_____ Female:____ Birth date:____/____/____ Age:_____ Race:___
Name of Person(s) with Whom Child is living:________________________
Relation to Child: ______________________________________________
Address: _____________________________________________________
City: __________________________ State: ______ Zip: ______________
Home Phone:_(_____)______________ Mobile Phone:(_____)__________
For Office Use Only
□Accepted □Denied Date: ______ Date Verified: _______ By: _____________ Turned into Child Nutrition Date: ______ Notice Sent to School Date: _________ PowerSchool Initials: ______ Date: ___________ |
Name of students Parent(s):
Mother -_____________________ Father -_________________________________
Step Mother -_________________ Step Father -____________________________
Who has *Legal Custody? ________________________________________________________ *(Legal Custody is referring to as permanent custody, not temporary by DHR or temporary pending court hearing or given by parent)
Name(s) of all others (not listed on page 1) Adults and/or Children living in household and relation to student:
Name: _____________________________________________Relation to Student: __________ Name: _____________________________________________Relation to Student: __________ Name: _____________________________________________Relation to Student: __________ Name: _____________________________________________Relation to Student: __________ Name: _____________________________________________Relation to Student: __________
Current Living Situation (Required)
Where is the student or students living right now? (Select only one.)
Briefly describe the student’s living situation: ______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Will this be a PERMANENT or TEMPORARY living situation? (circle one)
Reason(s) for current living situation
Please indicate the primary reasons for homelessness. (Please check all that apply.)
Declarations: Permanent Residency
Please enter the last date of permanent residency. ____________________
Does the student have any needs?
• Transportation to school of origin: Yes _____ No _____ School of origin: ______________
• School Supplies: Yes _____ No _____ (send list of items needed to FP Office)
• Health & Hygiene Supplies: Yes _____ No _____ (send list of items needed to FP Office)
• Clothing Items: Yes_____ No _____ (Contact FACT Worker assigned to school or Clothe Our Kids of North Alabama, http://fpdecatur.org/clothe-our-kids/)
Size: Pant _____ Under Garments _____ Shirt _____ Shoe _____ Socks _____ Coat _____
• Other Needs: ______________________________________________________________ In most cases fees for items such as lockers should be taken care of at the school level. Contact the Federal Programs office with questions and/or concerns 256-309-2126 or 2127.
Completed by: ____________________ Title: ____________________ Date: ______________
Declaration(s) of Understanding
School Counselor: By signing below you have verified the living situation of the student named in this application. Your verification and signature are required in order to process the application for homeless status.
School Counselor Signature: ____________________________________ Date: _____________
Guardian or Student Declaration
I declare that I am EITHER the parent/legal guardian of the student(s) named above who is/are of school age and is/are seeking enrollment in the Morgan County School System, OR I am an unaccompanied homeless youth who is of school age and is seeking enrollment in the Morgan County School System. I give Morgan County Schools permission to release my contact information to a Morgan County FACT worker in order to provide additional assistance.
Signature: ____________________________________ Date: _____________
All information in this questionnaire is required. Any missing information will delay processing of the application. Once the application has been received and reviewed, you will be notified by receipt of a copy of this application completed by this office. Should you have questions or need assistance, please contact Kristy Anders at (256) 309-2126 or Honi Smith at (256) 309-2127. Once a student has been identified as homeless, they will remain in homeless status for the remainder of the school year. A new homeless application must be submitted each year for students who remain homeless in consecutive school years.