LA Residency Questionnaire Form
This form is an electronic adaptation of the state mandated form, for the purposes of identifying homeless families so that they may receive the services and supports afforded to them under the federal McKinney-Vento Act. To view the original form in multiple languages go to the LDOE website: and scroll down to "Homeless Education Services"
Email *
Student Name *
Campus *
Gender *
Address *
Telephone *
Last School Attended *
Current Grade *
Date of Birth *
Parent/Guardian/Adult Caring for Student *
Relationship to Student: *
This questionnaire is intended to address the McKinney-Vento Act. Your child may be eligible for additional educational services through Title I Part A, Title I Part C Migrant, Individuals with Disabilities Education Act (IDEA) and/or Title IX, Part A, Federal McKinney-Vento Assistance Act, 42 U.S.C.11435. Eligibility can be determined by completing this questionnaire. It is illegal to knowingly make false statements on this form. If eligible, students are to be immediately enrolled in accordance with Bulletin 741, section 341.
Is the student's address a temporary living arrangement? (Choose "No" if this is a permanent living arrangement or the family owns or rents their home, and submit form.) *
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