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JFABD-E2 - Sample Housing Information Form

JFABD-E2 - Sample Housing Information Form

Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act. 

Student ____________________________ Parent/Guardian _________________________

School _________________________ Phone _____________________________                

Age _____   Grade _____           D.O.B. __________

Address ________________________________________________City _______________

Zip Code _______________  Is this address Temporary or Permanent? (circle one)

Please choose which of the following situations the student currently resides in (you can choose more than one):

_____ House or apartment with parent or guardian

_____ Motel, car, or campsite                                                                                             

_____ Shelter or other temporary housing

_____ With friends or family members (other than or in addition to parent/guardian)

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

_____ Loss of housing

_____ Economic situation

_____ Temporarily waiting for house or apartment

_____ Provide care for a family member

_____ Living with boyfriend/girlfriend                                  

_____ Loss of employment

_____ Parent/Guardian is deployed

_____ Other (Please explain)

Are you a student under the age of 18 and living apart from your parents or guardians? 

 Yes       No

Housing and Educational Rights

Students without fixed, regular, and adequate nighttime residences 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].

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



Signature of Parent/Guardian/Unattached Youth                  Date


Signature of McKinney-Vento Liaison                                     Date



Exhibit Form Revised: October 21, 2020

Cross-Reference: JFABD - Education of Homeless Students