EmailMe Form - CODCA Homeless Residency Info For Determination

Person Filling Out This Form

Presently, where is the student(s) living? (Check one box) *

House or Apartment With Parent or Guardian

Sheltered (EFAA, Safehouse, Youth Shelter, Emergency/Temporary Foster Care, etc.)

Doubled Up Due to Economic Hardship with Family or Friends

Unsheltered (Cars, Parks, Campgrounds, etc)

Other

If you are living in shared housing, please check all of the following reasons that apply:

Primary Nighttime Residence

Shelters / Transitional Living

Doubled Up Due to Economic Hardship

Unsheltered (Cars, Parks, Campgrounds

Is the student under the age of 18 and living apart from your parents or guardians? *

Student 1 *

Student 1 Grade Level *

Student 2

Student 2 Grade Level

Student 3

Student 4 Grade Level

Student 4

Student 3 Grade Level

Parent(s)/Legal Guardian(s) *

Address / Contact info
(Temp address / cross streets / family staying with, etc) *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone Number

### - ### - ####

Is this address Temporary or Permanent? (mark one) *

Yes

No

Immediate student/family needs, including internet, computers, transportation to state testing

Residency and Educational Rights
Students without fixed, regular, and adequate living situations have the following rights:
1) Immediate enrollment in the school they last attended or the local school where they are currently
staying even if they do not have all of the documents normally required at the time of enrollment
without fear of being separated or treated differently due to their housing situations;
2) Transportation to the school of origin for the regular school day;
3) Access to free meals, Title I and other educational programs, and transportation to extra-curricular
activities to the same extent that it is offered to other students.
Any questions about these rights can be directed to the local McKinney-Vento Liaison at [Insert phone number]
or the State Coordinator at [Insert phone number].

Additional Comments

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

Signature of Parent/Guardian/Unattached Youth *