Verification Of Student Admission Information (For Student Residing With Parent Or Guardian)/proof Of Residency Form (Page 2 of 13) in pdf

Student Residency Questionnaire

Student ID

Red Oak Independent School District

Teacher

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help

determine the services the student may be eligible to receive. A questionnaire must be completed for each child enrolling in the Red

Oak Independent School District.

Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false

documents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3) (d)



Name of Student _________________________________________________________________________ Gender:

Male

Female

Last

First

Middle

Birth Date:

__________/__________/__________

School: _______________________________________ Grade: __________

Month

Day

Year

Check the box that best describes with whom the student resides (Please note: Legal guardianship may be granted only by a court. Students

living on their own or with friends or relatives who do not have legal guardianship are allowed to enroll in and attend school. The school

cannot require proof of guardianship for enrollment or continued attendance.)



Parent(s)/Legal Guardian(s)

Caregiver(s) who are not legal guardian(s) How long? _______

Other________________________

(Example: friends, relatives, parents of friends, etc)

Describe

Name of person with whom student resides: _____________________________________________________________________________

Address _________________________________________________________________________ Phone __________________________

Check one box that best describes where the student is presently living. (Please note: Proof of residency is not required for students who

live in temporary situations due to loss of housing or economic hardship)



In my own house or apartment, in Section 8 housing, or in military housing with parent(s), legal guardian(s), or caregiver(s)



In the home of a friend or relative because I lost my housing(Examples: fire, flood, lost job, divorce, domestic violence, kicked out

by parents, parent in military and was deployed, parents(s) in jail, etc.) Name of Apartments___________________________________



In a Shelter because I do not have permanent housing (Example: living in a family shelter, domestic violence shelter, children/youth

shelter, FEMA housing) in Transitional Housing (housing that is available for a specific length of time only and is partly or completely

paid for by a church, a nonprofit organization, or another organization)



In a motel/hotel (because of economic hardship, eviction, cannot get deposits for permanent home, flood, fire, hurricane, etc.)

Name of motel ___________________________________________________City__________________________________________



Unsheltered (Examples: in a tent, car, van, abandoned building, on the streets, at a campground, in the park, or other unsheltered

location)

Please provide the following information for school-age siblings (brothers and/or sisters) of the student:

Child

School

Grade

DOB

Parent/Legal Guardian/Unaccompanied Youth __________________________________________________ Date ____________________

Signature

For school use only

Procedures:

1. If this child has immediate needs, the parent/student may call the Student Family Services office at 972-617-4658 for services

2. If any of the boxes A-D are checked, immediately scan and email the completed form to the District Homeless Liaison, Donna Knight at

for approval and Food Service authorization

Other needs expressed by the student, parent or guardian ________________________________________________________________________________

Interviewer ______________________________________________________Referral Date __________________Entry Date _________________________

Verification Of Student Admission Information (For Student Residing With Parent Or Guardian)/proof Of Residency Form Page 2

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