Student Homelessness

1.	Name*

2.	Date of Birth*
	mm/dd/yyyy

3.	Gender*
	Gender* Female Male Other

4.	Name of your school*

5.	Grade Level*

6.	Do you live in a:*
	Shelter    Motel/Hotel    Temporarily with another family in a house, mobile home, or apartment due to economic hardship    Car or RV    Campsite    Transitional Housing    Other Housing    Other, please specify

7.	Do you live with another family in a house, mobile home, or apartment due to economic hardship*
	One parent    Two parents    A qualified relative    Friend(s)    Adult who is NOT the legal guardian    Alone with no adults    Not applicable

8.	Do you and/or your student live in a fixed, regular, adequate nighttime resident?*
	Do you and/or your student live in a fixed, regular, adequate nighttime resident?* YesNo

9.	Are you living with someone who is your legal guardian?*
	Are you living with someone who is your legal guardian?* YesNo

10.	Are you interested in going to college, if we can help?*
	Are you interested in going to college, if we can help?* YesNo

11.	Can we share this information with your school district office, so you can receive the benefits of the McKinney-Vento Act?*
	Can we share this information with your school district office, so you can receive the benefits of the McKinney-Vento Act?* YesNo

12.	If you are interested in being contacted by a Homeless Advocate or Liaison, to see what student services are available to you, please include your name, and contact information (phone, email address, etc.) in the box below.