Sequoia Schools
McKinney-Vento Eligibility Questionnaire

Name of School:

Name of Student:
Last First Middle

Male
Female

Birth Date: / / Age: Social Security #:
Month / Day / Year (or student identification #)

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11432. The answers to this residency information help determine the services the student may be eligible to receive.

1. Is your current address a temporary living arrangement? Yes No

2. Is this temporary living arrangement due to loss of housing or economic hardship? Yes No

If you answered YES to the above questions, please complete the remainder of this form.
If you answered NO, you may stop here.

Where is the student presently living? (Check one box.)
In a motel
In a shelter
With more than one family in a house or apartment
Moving from place to place
In a place not designated for ordinary sleeping accommodations (ex: car, park, campsite)

Name of Parent(s)/Legal Guardian(s)

Address: Zip: Phone #:

Signature of Parent/Legal Guardian Date

Please send a copy to McKinney-Vento Liaison:
Liaison's Name

I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act.

Date McKinney-Vento Liaison Signature