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McKinney-Vento Eligibility

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Required

The information requested on this form is required to determine eligibility for services provided per the McKinney-Vento Homeless Assistance Act (42 U.S.C Chapter 119, Subchapter IV, Part B), which ensures the educational rights and protections for youth experiencing homelessness (as defined by 42 USC 11434a[2]).

*If you own or rent your own home, you do not need to complete this form

Parent/Guardian/Caregiver Informationrequired
First Name
Last Name

Student Information

Student 1required
Student Name
Student ID#
Grade
School
Student 2
Student Name
Student ID#
Grade
School
Student 3
Student Name
Student ID#
Grade
School
Student 4
Student Name
Student ID#
Grade
School
Previous Living Situation
Did you rent/own/lease this address?
Was this a planned move or an unexpected one due to financial circumstances?
Current Living Situation
Which of the following best describes the student(s) temporary living situation?
Are you on the lease at the current address?
Are you currently paying rent/a fee to live here?
Could you be asked to leave this residence on short notice?
What else are you currently paying for?
Are you currently able to get our student(s) to and from school?

Contributing Factors

Which of the following applies to the cause of your present living situation? (Mark all that apply)

McKinney-Vento Services

If eligible, services that may be provided include:

  • Free meals at school

  • School supplies

  • Waived educational fees

  • Transportation (with some eligibility restrictions) to/from the school of origin for the duration of the school year

Verification of Information

*If you are an unattended minor, please fill out this section with your own printed name and signature.

I declare that the information provided is true and correct and of my own personal knowledgerequired

*If this form was completed by someone other than the Parent/Guardian/Caretaker, please fill out this section*:

I declare that the information provided is true and correct and of my own personal knowledge
Person Filling Out This Formrequired
First Name
Last Name
Must contain a date in M/D/YYYY format
Please fill out this information completely. Incomplete information will result in a delay of provided services. (Note: Fraudulent information suspected and verified will result in removal of services)