JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
McKinney-Vento
Faribault Public School District Families in Transition Liaison: Vonna Dinse, 507-333-6186
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
McKinney-Vento is federal legislation stating that students (and families) who are experiencing a period of instability with their housing may be eligible for additional educational services.
All information shared on this form is confidential and is for the sole purpose of ensuring the rights of children and youth under the McKinney-Vento act.
First Name of person completing the form
*
Your answer
Last Name of person completing the form
*
Your answer
Relationship to student
*
Parent/Guardian
School Staff
Family member
Friend
Other:
Best way to contact you for follow up information if needed (phone number/email address):
*
Your answer
The following situation has been indicated (if none of these applies, you more than likely do not meet McKinney-Vento's criteria):
*
Living in a shelter
In a motel, hotel, or weekly rate housing
Doubled up with friends or relatives because of loss of housing or unable to afford adequate housing
Living in a car, park, campground, public space, abandoned building, substandard housing or similar situation
On the street
WIth friends or relatives because you are an unaccompanied youth (youth not in the physical custody of a parent or guardian) that also meets the above criteria
First Name of student living in situation
*
Your answer
Last Name of student living in situation
*
Your answer
School student is attending
*
Your answer
Grade student is in
*
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Other:
List of other students impacted by the same living situation:
Your answer
Was a parent/guardian present?
*
Yes, person filling out the form is the parent/guardian
Yes, parent is aware/present
No parent present
Student is an unaccompanied youth
Other:
If parent/guardian present, what is the best way to reach them? Please include email address and/or phone number:
Your answer
Additional information about the situation:
Your answer
Follow Up:
A follow up contact may be made for required signatures and/or additional information.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Faribault Public Schools.
Report Abuse
Forms
