ACADEMIA DEL PUEBLO STUDENT QUESTIONNAIRE(English)
This questionnaire is intended to address the McKkinney – Vento Act 42 U.S.C 11435. The answers to this questionnaire information help determine the services the student may be eligible to receive.

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Name of School
First and Last Name of Student
Student Date of Birth
Student Age
Gender
Clear selection
Presently, where does the student stay at night? Please check one:
1. Is your current address a temporary living arrangement?
Clear selection
Presently, where does the student stay at night? Please check one:
2. Is this temporary living arrangement due to loss of housing or economic hardship?
Clear selection
If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, please sign and date the bottom.
Where is the student presently living? (Check one box.)
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Type First and Last Name of Parent/Legal Guardian
Parent/Legal Guardian Address
Date filling out this form
MM
/
DD
/
YYYY
I certify that the above- named student qualifies for the Child Nutrition Program under the provisions of the McKinney – Vento Act
Date of Certification
MM
/
DD
/
YYYY
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