Residency Questionnaire

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Parent/Guardian/Student:
This form is intended to address the McKinney-Vento Act 42 U.S.C. 11435, and must be completed for each
student. The information you provide is confidential. Your child will not be discriminated against based upon the
information provided.

Please complete the following questions regarding the student’s housing in order to help determine services the student may be eligible to receive.

Note to schools/Temporary Housing Liaisons: Please assist students and families in filling out this form. Do not simply include this form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required to submit proof of residency and other required documents that may be part of the registration packet.

Student Name (Last, First, Middle) *

OSIS Number *

Student date of birth *

YYYY

The telephone number to best reach family *

Gender *

School *

Please identify the student’s current living arrangements. Please select one: *

Double-Up (With another family or other person because of loss of housing or as a result of economic hardship)

Shelter (Emergency or transitional shelter)

Awaiting Foster Care Placement

Hotel/Motel (Living in what is NOT an emergency or transitional shelter and involves payment)

Other Temporary Living Situation (Trailer park, campground, car, park, public spaces, abandoned building, street, or any other inadequate living space)

Permanent Housing (Student who is living in a fixed, regular, and adequate housing situation)

Required

If the student is NOT living in permanent housing, also indicate if this applies:

Unaccompanied Youth (Youth who is not in the physical custody of a parent or guardian)

Other:

Clear selection

Parent or guardian filling out this form *

Submit

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This form was created inside of The Antonia Pantoja Preparatory Academy.

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