Homeless Children & Youth – Identification/Referral Form

Chippewa Falls School District – 2015-16 School Year

Definition of Homelessness: The phrase “homeless children and youth” means individuals who lack fixed, regular, and adequate nighttime residence due to economic hardship. It includes children and youth who are temporarily sharing the housing of another person due to the loss of housing, economic hardship, or a similar reason or are living in emergency shelters, temporarily housed while waiting for foster care placement, in a motel, hotel, car, campground or similar situation due to lack of housing.

Homeless children and youth have certain educational rights that have to be addressed – the completion of this form will start the process of ensuring that homeless children and youth have access to a quality education despite their living conditions. Please fill out as much of this form as possible with as much detail as possible. Send, fax, or e-mail it to the District Homeless Liaison (Contact information given below.) Email is preferred so the form can be saved electronically. Be aware that information regarding homelessness is to be kept confidential.

Chippewa Falls School District – Homeless Liaison:Dave Schaller – Alternative Programs Principal

Mailing Address: 1130 Miles Street, Chippewa Falls, WI 54729

Phone: 715-723-5542, ext. 6401Fax: 715-720-3762

E-mail:

Supply as much of the following information as possible. This information will allow us to best meet the

educational needs of the student(s). Fill out only one form per family. (Please fill out both sides of the form.)

Part I: Required Information for ESEA Reporting Purposes

Referral Date:
Homeless Start Date: / Person Making Referral:

Homeless Student

/

School

/ Grade (PreK-12) /

M/F

/ Spec Ed (Y/N) / ELL (Y/N) / G/T (Y/N)
Homeless Status (check one):
Living with family
Separated from family
Foster care pending
Runaway
Unaccompanied youth
Released from penal institution
Abandoned
Throwaway (Kicked out of home. Possibly due to pregnant, AODA issues, family conflicts, etc.)
Other Specify / Living Arrangements (check one):
In a shelter
Doubled-up
In a hotel/motel
Unsheltered (on the street, car, park, campground, abandoned building)
Unknown
Definitions:
Shelters—includes children and youth living in emergency shelters, transitional living programs, and children and youth awaiting foster care placement.
Doubled-up—sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason. This category includes children, youth, and unaccompanied youth who live with relatives, friends, boyfriends,
girlfriends, etc. because they cannot afford housing on their own. Unsheltered—children, youth or unaccompanied youth who live in abandoned buildings or apartments, bus and train stations, campgrounds, cars, parks, public spaces, trailer parks, children abandoned in hospitals, and children and youth who live in substandard or inadequate housing.
Hotels/Motel—children, youth, and unaccompanied youth who are temporarily living in hotels and motels because they cannot afford other types of housing.
Unknown—any living situation not included above.

Part II: Family Information

Parents/Guardians: / Phone 1.
Numbers 2.
3.
Description of Living Situation:
Address:
People Living with (if appropriate):
Other Important Details:
Educational needs that aren’t being met:
Other basic needs that aren’t being met:
Transportation Needs:
Additional Concerns:
For use by Homeless Liaison:
Added to HIT Emailed to FS & Title 1 IC Updated
Comments/Notes: