Student Homelessness
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Student Homelessness Survey
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?
*
Yes
No
9.
Are you living with someone who is your legal guardian?
*
Are you living with someone who is your legal guardian?
*
Yes
No
10.
Are you interested in going to college, if we can help?
*
Are you interested in going to college, if we can help?
*
Yes
No
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?
*
Yes
No
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.