LUBBOCK ISD - FEDERAL PROGRAMS DEPARTMENT

Student Residency Questionnaire

2008-2009
This questionnaire is intended to address the McKinney-Vento Homeless Education Assistance Improvements Act 42 U.S.C. 11435.  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 the form.
If you answered NO, you may stop here and do not send this form to Federal Programs
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Where is he 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 designed for ordinary sleeping accommodations such as a car, park, or campsite
Other: Please Specify:
 
Students Last Name: First Name: Middle Initial:
Gender Male    Female Birth Date:
Student's School: Grade:
Name of Parent (s)/Legal Guardian (s):
Address: Zip: Phone:
 
Signature of Parent/Legal Guardian: _______________________________________ Date: ________________
 

UPON RECEIPT OF THIS FORM, STUDENT IS APPROVED FOR THE FREE LUNCH PROGRAM
 
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)
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TO BE COMPLETED BY CAMPUS
 
Referred by: ___________________________________ Contact Phone Number: __________________________
  (Counselor/Nurse/Home Liaison/Principal/Other)  
 
Approved by: ______________________________________ Date: __________________________
 

Campus Administrator

    
 
Comments: ____________________________________________________________________________
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FAX COMPLETED FORM TO BONNIE QUINTANA IN FEDERAL PROGRAMS (806) 766-2226