2025-2026 McKinney-Vento Housing Questionnaire

Name of School:*

Name of Student:*

First NameLast Name

Student's Age:

Student's Birthdate

Date

Parent/Guardian Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Parent/Guardian Email*

example@example.com

TemporaryPermanent

Address (if available - primary location student stays):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

House or apartment with parent or guardianMotel, car, or campsiteWith friends or family members (other than parent/guardian)Shelter or other temporary housing

YesNo

Residency and Educational Rights

Students who are in temporary, inadequate, and homeless living situations have the following rights:

1) Immediate enrollment in the school they last attended or the school in whose attendance area they are currently staying even if they do not have all of the documents normally required at the time of enrollment;

2) Access to free meals and textbooks, Title I and other educational programs, and other comparable services including transportation;

3) To attend the same classes and activities that students in other living situations also participate in without fear of being separated or treated differently due to their housing situations.

Any questions about these rights can be directed to the local McKinney-Vento Liaison at

(765) 455-8000 or the State Coordinator at (800) 833-2199.

By signing below, I acknowledge that I have received and understand the above rights.

Parent/Guardian Signature:

Student Signature (for unaccompanied homeless youth only)

Date:*

Date