McKinney-Vento Homeless Assistance Act Student Identification Form

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Please fill in all sections of this form. A separate form must be filled out for each child you have attending Lincoln Park Public Schools.

School *

Date student identified and/or enrolled: *

YYYY

Student Name *

Last 4 digits of SS#

Date of Birth *

YYYY

Gender

Race/Ethnicity

Current Grade Level *

Parent or Guardian Name: *

Temporary Address: *

Street number, Street name, Apartment Number (if applicable), Zip Code

Phone Number: *

Alternate Phone Number:

Is parent a veteran? *

Yes

Current Living Situation: *

Temporarily sharing a house with another person due to loss of housing, economic hardship, or similar reason.

In a motel, hotel, or campground due to lack of alternative accommodations

In an emergency or transitional shelter or hospital

Awaiting Foster Care placement

In a living arrangement not described about that is not fixed, regular or adequate

Unaccompanied Youth and/or Runaway

None of the above

Brief description of circumstances leading to this living situation: *

How long has the child lived in this situation: *

Expected length of stay in this situation: *

Number of children between the ages of 0 - 2 in the household: *

Number of children (not in kindergarten) between the ages of 3 - 5 in the household: *

Transportation requested: *

Yes

Other Needs:

School Clothing

Backpack

School Supplies

School Activity Fees

Previous district programs this student was enrolled in and/or in need of:

Special Education

Section 504

Gifted/Talented

Academic Support

English Language Learner

Behavior Support

Vocational Education

Student Attending Alternative School

Is contact from Wayne Metro CAA requested? *

Yes

By signing this form electronically I declare that I am the parent/legal guardian of the above named student that is seeking enrollment. 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 that, if called to testify, I would be competent to do so.

I am aware that information will be exchanged between this school and Wayne-Metropolitan Community Action Agency in order to provide services to this student under the McKinney Vento Act.

I have received information regarding rights and protections under the McKinney Vento Homeless Assistance Act.

Parent Signature *

Please type your full legal name.

Date *

Please type the date this form was completed.

YYYY

Important Notice: If you have another child who is of school age that will be attending Lincoln Park Public Schools please submit another form for that child as well. Thank you.

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