ECYEH - Homeless Intake Form
Please complete this form in regards to any student who you may believe is experiencing homelessness.

This form is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The confidential information in this form will determine the services that the students may be eligible to receive.
Email *
Date of Identification
MM
/
DD
/
YYYY
Student Name (please list all children in the family)
Date of Attendance after Identification
MM
/
DD
/
YYYY
Email Address *
Temporary Address
Phone Number
Date of Birth (for 1st child listed)
MM
/
DD
/
YYYY
Gender
Clear selection
Grade level
School District / Building (for first child listed)
Clear selection
Parent / Guardian
Current Nighttime Status
Clear selection
Method of Identification
Clear selection
Precipitating Event
Clear selection
student status
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Greater Nanticoke Area School District.

Does this form look suspicious? Report

Google Forms