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Student/Family Residency Survey

A student may be eligible for additional educational services through Title I and/or the McKinney-Vento Act. Eligibility may be determined by answering the questions below:

Rhonda Herrington, the Homeless Liaison, will reach out to the parents and/or student(s) with eligibility results and related services.

Does the family or student have a fixed, regular, and adequate nighttime residence? *

Yes

Name of Parent/Guardian or Unaccompanied Youth *

Email Address of Parent/Guardian or Unaccompanied Youth: *

Phone Number of Parent/Guardian or Unaccompanied Youth: *

Mailing Address: If there is an address where school related mail should be sent:

Does the family or student reside in any of the following living arrangements? (check all that apply) *

Student/Family is in a shelter (family shelter, youth shelter, emergency shelter).
Student/Family is unsheltered (on the street, campground, park, abandoned building, or inadequate accommodation).
Student/Family is staying in a public or private place not designated for or ordinarily used as a regular sleeping accommodation (vehicle, public restrooms, bus station, etc.).
Student/Family is in a hotel/motel due to loss of housing, economic hardship, or similar reason.
Parent(s) are migrant workers.
Student/Family is TEMPORARILY staying with friends or relatives.
Student is not living with parent or legal guardian.
Student/Family is staying with friends or relatives indefinitely (long term/cultural living arrangement)

Please describe the current living arrangements in detail. *

Please describe the circumstances that led to this arrangement? *

Please list all school-aged children living in this living arrangement:

Name	Grade

Role of the person completing this form: *

Parent
Guardian
Student
Family Member
Concerned Citizen
BWSD Staff

By signing, I certify that the above information is correct to the best of my knowledge. I also understand someone from the Bay St. Louis-Waveland School District's Federal Programs department will call to verify eligibility for homeless services.

Type your name and sign below

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Approvals

A number of approval stages need to be completed before this submission can be accepted.

Federal Program Secretary

Please select the appropriate approvers from the Federal Program Secretary group below.
Please select your principal/supervisor

Tracy Shields

Federal Programs Director

Appropriate approvers from the Federal Programs Director group will be automatically allocated for this approval stage.