Burlington-Edison School District Housing Questionnaire

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Please complete the attached form if your housing situation has changed. The answers to the following questions can help determine the services that students may be eligible to receive under the Mckinney-Vento Act 42 U.S.C. 1143555

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E-Mail-Adresse *

Student Full Name *

Student Date of Birth: *

Student is living with Parent or Guardian? *

Yes

Grade *

Pre-School/Opportunity Kindergarten

School *

B-EHS

Allen

Bay View

Edison

Lucille Umbarger Middle School

West View Pre-School

Reason *

In a motel **Must Include details below

In a shelter **Must Include details below

Transitional housing **Must Include details below

In someone's else's house or apartment with another family **Must Include details below

Moving from place to place (couch surfing) **Must Include details below

A car, park, campsite, or similar location **Must Include details below

In a residence with inadequate facilities (no water, heat, electricity, etc.) **Must Include details below

Other **Must include details below

Please provide additional Information about your situation. Please be specific. If living with another family, please note family contact and phone number: *

Current Address: *

Previous Address: *

Phone/Contact Number: *

Contact Name: *

Translation Services Needed: *

Yes

If so what Language:

School Transportation Needed? *

Yes

If siblings, please write name, grade, and school

Electronic Signature: First/Middle/Last *

Acknowledgment

The electronic signature and its related fields are treated by Burlington-Edison School District like a handwritten signature on a paper form.

I have reviewed the information provided on this form, and to the best of my knowledge, the information is correct and complete. I will be contacted if it is discovered that any information is incorrect, falsified, or incomplete.

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