McKinney-Vento Student Housing Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The answer to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness.

If you own/rent your own home, you do not need to complete this form.

If you do not own/rent your own home, please check all that apply below. *

0 points

In a motel

In a shelter

Moving from place to place/couch surfing

In someone else's house or apartment with another family

In a residence with inadequate facilities (no water, heat, electricity, etc.)

A car, park, campsite, or similar location

Transitional Housing

Other:

Required

First and Last Name of Student *

Name of School (in attendance or seeking attendance in) *

Grade *

Birth date (month/day/year) *

YYYY

Age *

Gender *

Male

Female

Prefer not to say

Other:

Who does the student live with? *

Student is unaccompanied (not living with a parent or legal guardian)

Student is living with a parent or legal guardian

Address of Current Residence *

Phone Number *

Name of Contact *

Name of Parent or Legal Guardian *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Kennewick School District.

Does this form look suspicious? Report

Forms