McKinney-Vento Residency Form

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2020-2021 School Year

The questions below are to assist in determining if students meet the eligibility criteria for services provided under the McKinney-Vento Act.

The McKinney-Vento Homeless Education Assistance Act is a federal law that ensures immediate enrollment and educational stability for displaced children and youth. The information you provide will be kept confidential.

If you have any questions or concerns, please call the Manchester School District Homeless Education Liaison, Jocelyne Pinsonneault at 665-6868.

Are you temporarily staying in one of the following places due to loss of housing or economic hardship?

****PLEASE DO NOT CONTINUE FILLING OUT THIS FORM IF ABOVE DOES NOT APPLY TO YOU****

It is the policy of the Manchester Board of School Committee, in its actions, and those of its employees, that there shall be nondiscrimination on the basis of age, sex, race, color, marital status, physical or mental disability, religious creed, national origin or sexual orientation for employment in, or operation and administration of any program or activity in the Manchester SchoolDistrict.

Email *

Are you temporarily staying in one of the following places due to loss of housing or economic hardship? *

In a motel/hotel

In a shelter (Families in Transition, Emergency Shelter, Rooming House)

With more than one family (sharing a house or an apartment

Moving from place to place

In a place not design for ordinary sleeping accommodations, such as a car, park, campsite

Required

Name of your student(s) in Manchester School District if ONLY if the above applies to you. You only need to fill out ONE form per family). [FIRST AND LAST NAME, GRADE, SCHOOL] *

Do you have a preschooler at home? *

Yes

Are you the *

Student's Parent

Student's Guardian

or an Unaccompanied Youth*

Address where student(s) is/are staying [House # Street, APT# CITY, STATE, ZIP] *

Best Phone Number [indicate cell or home] *

Under penalty of perjury under the laws of this state, I declare that the information provided here is true and correct and of my own personal knowledge, and if called upon to testify, I would be capable to do so. *

Yes, I understand

No, I do not understand

Name of person completing this form [FIRST NAME LAST NAME] This serves as your signature of acknowledgement *

Send me a copy of my responses.

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