Author: Lynne Jacobs

Student Residency Form

This form is intended to address the requirements of the McKinney-Vento Act (Title X, Part C of the No Child Left Behind Act). The question below is to assist in determining if the students meets the eligibility criteria for services provided under the McKinney-Vento Act. In the event that the child is not staying with his/her parent (s) or guardian (s), use the caregiver authorization form to address guardianship issues.
Part A: Does the student live in a home that belongs to a parent/guardian (rented or owned) ?
______YES _________NO (If yes, go to Part B.)
Where does the student stay at night?
________ in a shelter ________ in another location that is not appropriate for people
(e.g., an abandoned building)
________ in a motel/hotel ________ temporarily with more than one family in a house, mobile home,
or apartment (because the family does not have a place of its own)
________ in a car ________ other (in an arrangement that is not fixed, regular, and adequate and adequate and is not described by the other choices)
________ at a campsite
Name of School: __Rippleside Elementary School
I, (name) _________________________________________________________________________
declare as follows:
I am the parent/legal guardian of (name of student) ____________________________________________
Who is of school age and is seeking enrollment in (name of school district) _ISD #1
Since (date) _____________, our family has not had a permanent residence.
Part B:
Name of Student : _____________________________________Student’s Date of Birth: _____________
Under penalty of perjury under the laws of this state, I declare that the information provided here is true and correct and of my own personal knowledge and that , if called upon to testify, I would be competent to do so.
Name of person completing the form: ______________________________________________________