20          – 20          School Year

The following questions will help Granite School District determine eligibility for additional services for students and families. Please fill this form out and return to McKinney-Vento Liaison.

Submission of any false or misleading information is a violation of state law and may void this application and agreement.

Yes / No

     Is the student sharing housing with another person or family due to loss of housing, economic hardship, or similar reasons?

     Is the student living in a motel or hotel?

     Is the student living in a shelter or temporary housing?

     Is the student living in a car, park, campground, public space, abandoned building?

     Is the student living in housing with infestation, mold, or does not have heat, electricity, or water?

     Is the student unaccompanied, without a legal guardian, and not in foster care or state’s custody?

If you answered YES to ANY of the above questions, please complete the remainder of this questionnaire.

Please notify the school if your living status changes.

Student Name:                                                                                                      Student ID #                     

School:                                                                                                                              Grade:                   Date:                                           

Student’s Phone Number if applicable:___________________

Note: If this questionnaire concerns an unaccompanied youth, please include a phone number. No other information is needed.

Parent/Legal Guardian/Caregiver Name (Print):                                                                       

Parent/Legal Guardian/Caregiver Name (Signature):                                                                       

Address:                                                                                                                              

Telephone No.                                         

Relationship to student:                                                             

List all school age siblings of the above named student residing with you.

Name	Student #	School	Grade

Parents/Legal Guardians/Caregivers: If you have any questions concerning this questionnaire or a homeless situation, please contact: Holly Chappell, 385-202-5603

RETURN THIS FORM TO THE HOMELESS LIAISON, FAMILY AND COMMUNITY ENGAGEMENT DEPARTMENT

Granite School District • 2500 South State Street • Salt Lake City, Utah   84115-3110