Lyon County Schools                                     McKinney-Vento Intake Affidavit
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Student's Name: *
ID#
Date of Birth: *
Age: *
Grade:
Gender: *
Povinné
Parent/Guardian Name(s): *
Phone Number(s: *
Address:
Home School (based on current residence)
School of Origin (last school attended)
Siblings of Student:
School of Siblings:
Is there a copy of your student's Birth Certificate on file at school?
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If you answered NO, do you need assistance with obtaining a copy?
Zrušit výběr
If you answered YES, please list your child's birth city and state below:
Where is this student currently living? (check box) *
Povinné
Name of hotel/motel, transitional housing, or shelter.
How long have you lived at this residence? *
How long do you plan to live at this residence? *
With whom does the student currently live: *
Please name which parent, grandparent, relative, or other adult with whom student lives.
Describe the current living situation in detail.
Any possibility of violence or abuse in home
If marked "Yes" for violence or abuse, please describe. What were the school's actions?
In your child's previous school, did he/she receive any of the following? Check all that apply
At this time, what is the greatest need for your child? Check all that apply *
Povinné
Other needs: Please describe:
My signature below affirms the following: (1) the information I have provided on this form is true and accurate to the best of my knowledge or belief; (2) the same information, as well as other information that may identify m child(ren), may be shared with my consent with community and governmental agencies pursuant to an interagency collaboration between this school district, Lyon County Human Services, and Healthy Communities Coalition; (3) the same information, as well as other information that may identify my child(ren), may be shared with my consent with other LCSD staff members for a legitimate educational purpose. In addtion, my signature affirms that I have received a copy of my rights under the McKinney_Vento law and I agree to allow LCSD staff to conduct screenings as a part of the district's McKinney-Vento program. *
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Parent/Guardian Signature and date (By typing my name, I am signing this form) *
I consent to sharing the information on this form with any community and/or governmental agency. *
MCV LIAISON SIGNATURE /DATE (for school use only)
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