Families In Transition Program (Student Residency Questionnaire)
Student Residency Questionnaire: Please complete one form per child. This will ensure accuracy of information.
Section A. Student Information
Student Name
Gender
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Grade
School
Clear selection
Section B. Parent/Guardian Information
Name of Parent/Guardian
Current Street Address
City
Zip Code
Home Phone Number
Cell Phone Number
Email Address
Section C. Program Eligibility
Please Check All That Apply
Section D. Residential Status
If you, your child, or a child in your care has experienced any of the following descriptions during this school year, please enter a check mark for each that applies.
Section E. Cause of Temporary Residence
Please check the reason that most describes your condition
Clear selection
Section F. Only Unaccompanied Homeless Youth Must Complete This Section
An unaccompanied youth is any student not living in the physical custody of a parent or legal guardian.
If you are an unaccompanied homeless youth, what is the living status?
Clear selection
If living alone without an adult, how long have you been living alone?
If living with an adult that is not a parent or legal guardian, please provide the following information:
Caregiver Name:
Caregiver's relationship to student:
Caregiver's phone number:
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