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McKinnney Vento - Student Residency Questionnaire
This information will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act. All information obtained for this purpose will remain confidential. One form per student enrolled is required.
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* Indicates required question
Email
*
Your email
Student's Name:
*
Your answer
Student's Gender:
*
Male
Female
Date of Birth:
*
Your answer
Grade:
*
Your answer
School/Campus:
*
Elementary
Intermediate
Middle School
High School
Parent/Guardian Name:
*
Your answer
Relationship to Student:
*
Your answer
Current Address:
*
Your answer
Phone #:
*
Your answer
Last School Attended:
*
Your answer
Previous Address:
*
Your answer
Total # of Children Enrolled in GISD:
*
1
2
3
4
5
6+
1. Is your Current Address a TEMPORARY living arrangement?
*
Yes
No
2. Is this a TEMPORARY living arrangement due to loss of housing, economic hardship, or financial difficulties?
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Yes
No
If you ANSWERED NO to both of the questions above, do NOT complete the rest of the form. Click "SEND" to submit this form. If you ANSWERED YES to one or both of the questions above, please complete the rest of the form. Click "SEND" to submit the form after completion.
Section A - STUDENT living situation (check ALL that apply):
House or apartment with parent or guardian (and do not share home with any other family)
Sharing housing with friends or family members (other than or in addition to
Motels/Hotels
Shelter or other transitional housing
Unsheltered – in a tent, car, park, substandard housing, etc.
Unaccompanied Youth (student is NOT living in the home of a parent or legal guardian)
Child or youth paced by DFPS with a temporary guardian (DFPS provided a Parental Child
Safety Plan or Authorization for Non-Parent or Voluntary Caregiver)
Section B - FACTORS contributing to the current living situation (check ALL that apply):
Natural disaster - tornado, storm, flood, hurricane, fire, etc.
Loss of housing
Loss of employment
Economic hardship - Loss of job, eviction, etc.
Family issues such as divorce, domestic violence, kicked out by parents, student left due to family conflict
Home issues such as lack of electricity, water, heat, adequate home repair due to lack of funds, overcrowding, mold, etc.
High medical bills that leave little or no money for housing
Parent/Guardian is currently on active duty in the U.S. Military
Incarceration of Parent/Guardian
Minor student unable to afford housing on my own
None of the above describe the main reason for my present living situation.
Other:
YOUR Name (parent/guardian):
*
Your answer
Date:
*
MM
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YYYY
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