SAMPLE RESIDENCY QUESTIONNAIRE (Form 1)

SAMPLE SCHOOL DISTRICT
STUDENT RESIDENCY QUESTIONNAIRE FORM 1

SAMPLE RESIDENCY QUESTIONNAIRE (Form 1)

Today’s Date: ______

Student Name: / Date of Birth:
Parent/Guardian Name: / Phone #:
School: / Grade:
Current Residence Address or Location:

Please answer the questions below concerning your residency. The information you provide is confidential. The answers to these questions help determine services and ensure the rights of your child under the McKinney-Vento Act (Subtitle VII-B, Title IX, Part A of the Every Student Succeeds Act)

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
3. Is the loss of housing due to a fire, earthquake, hurricane, flooding or another natural disaster? YES NO
4. Name of natural disaster (e.g., Hurricane Katrina, California Wildfires, etc.): ______

If you answered YES to the above questions please complete the remainder of the form.

If you answered NO, you may stop here.

Where is the student currently living? (Please check one)

With a relative, friend, or another family in their house/apartment

In a hotel/motel – name of hotel/motel: ______

In an emergency shelter, transitional housing/shelter, or domestic violence shelter—name of shelter/program: ______

In a location not designed for sleeping such as a car, trailer, park, or campground

In housing that is inadequate (e.g., no electricity, running water, etc.)

Other situation—describe: ______

I declare that the information above describes my family’s current living situation and that that information is true and accurate to the best of my knowledge or belief. I understand that providing false information is punishable by law and will impact my child’s enrollment in school.

Signature: / Relationship to Student: / Date:

SCHOOL ENROLLMENT FORMS (Forms A-D)

SAMPLE SCHOOL DISTRICT
Declaration of Residency & McKinney-Vento Eligibility Assessment FORM A (parent completes)

A student may qualify for additional services at school due to his/her current living situation. The information on this form is needed to determine eligibility for services under the McKinney-Vento Homeless Assistance Act, Subtitle VII-B, Title IX, Part A of the Every Student Succeeds Act. The information you provide is confidential and the student will not be discriminated against based upon the information provided.

Student Name: / Date of Birth:
Parent/Guardian Name: / Phone #:
Last School Attended: / Today’s Date:
Current Residence Address or Location:
Current Mailing Address (if different from Residence Address)

1. Where is the student currently living?

With a relative, friend, or another family in their house/apartment

In a hotel/motel – name of hotel/motel: ______

In an emergency shelter, transitional housing/shelter, or domestic violence shelter—name of shelter/program: ______

In a location not designed for sleeping such as a car, trailer, park, or campground

In housing that is inadequate (e.g., no electricity, running water, etc.)

Other situation—describe: ______

1. Why is the student living in the above situation?

Loss of housing due to eviction/foreclosure

Financial hardship (lost job, rent too high, behind on bills, unable to pay deposits for own housing, etc.)

Domestic Violence

Natural disaster (fire, flood, earthquake, etc.)

Asked to leave by parent/guardian or ran away from home

Temporary situation—describe: ______

Other situation—describe: ______

1. Who is the student currently living with?

Parent(s)

A friend or relative who is a legal guardian—name and number: ______

A friend or relative who is not a legal guardian – name and number: ______

1. How long has the student lived at this residence?______

1. What was the last address where the student or family had housing of their own?

I declare that the information above describes my family’s current living situation and that that information is true and accurate to the best of my knowledge or belief. I understand that providing false information is punishable by law and will impact my child’s enrollment in school.

Signature: / Relationship to Student: / Date:

SCHOOL ENROLLMENT FORMS

SAMPLE SCHOOL DISTRICT
School Selection and Needs Assessment FORM B (Parent completes)
SCHOOL SELECTION

Students who qualify for services under the McKinney-Vento Act have two choices for school selection. The student may enroll in the school within the attendance area of your current temporary address or the student may remain in the last school he/she was enrolled in and attending at the time housing was lost. Please select the option you are seeking:

I would like to enroll my child in the attendance area of my current temporary address

I would like for my child to remain at his/her current school even though we are now living outside that attendance area

SIBLING INFORMATION

I am the parent/guardian of the following children (list all children, including infant, toddler and preschool children):

Name (First, Last) / Birthdate / School / Grade / Mark here if you’d like this child to remain at his/her current school

Mark here if you are requesting transportation for your child/children to remain in the current school

CURRENT NEEDS AND CONCERNS

Please mark all services that would be helpful to you. Assistance and/or referrals may be available.

Academic help/tutoring
Attendance/help getting to school
Backpack and school supplies
Hygiene items / Counseling or mental health needs
Food assistance
Clothing
Housing / Transportation to school
Health services
Help getting documents (e.g. birth cert., Calif. ID)
Other
SIGNATURES

I have received a copy of my rights under the McKinney-Vento law and the information has been explained to me, including my right to participate in the dispute process if I disagree with eligibility or placement.

I agree to the current school placement of my child

Signature of Parent: / Date:
Witness: / Date:
SAMPLE SCHOOL DISTRICT
Eligibility Decision & School of Origin/School Placement Decision FORM C (school staff completes)
ELIGIBILITY DECISION

Based upon the information provided by the parent in Form A and B and subsequent interview with staff the following determination of eligibility was made:

Student Name: / Birthdate:

MEETS ELIGIBILITY under McKinney-Vento requirements based upon the following information:

DOES NOT MEET ELIGIBILITY under McKinney-Vento requirements based upon the following information:

Parent has received notification regarding eligibility and school placement decisions including the right to participate in the dispute process

SCHOOL OF ORIGIN/SCHOOL PLACEMENT DECISION

Based upon parent/youth’s wishes and best-interest determinations the following school placement is recommended:

SCHOOL / GRADE / SCHOOL OF ORIGIN
RESIDENCE SCHOOL

BEST INTEREST CHECKLIST (The following were considered and were the basis for this determination)

School of Origin Consideration
(check which factors indicated school of origin
was in the child’s best interest) / Local School Consideration
(check which factors indicated local school
was in the child’s best interest)
Continuity of instruction / Continuity of instruction
Age and grade placement of the student / Age and grade placement of the student
Academic strength / Academic strength
Social and emotional state / Social and emotional state
Distance of the commute and its impact on the student’s education. / Distance of the commute and its impact on the student’s education.
Personal safety of the student / Personal safety of the student
Student’s need for special instruction / Student’s need for special instruction
Length of anticipated stay in a temporary shelter or other temporary location / Length of anticipated stay in a temporary shelter or other temporary location
TRANSPORTATION

Transportation to school of origin must be arranged promptly to ensure immediate enrollment and not create barriers to attendance, retention or success. Mark which option works best for this student (include all options district can offer):

School Bus Mileage Reimbursement Bus passesOther

Date transportation arranged: ______

SAMPLE SCHOOL DISTRICT FORM D (school completes & sends to parent)
Parent/Guardian Notification of McKinney-Vento Eligibility and Placement

Date:

Dear Parent/Guardian of ______

Based on the information that has been provided to the school, the following eligibility determination has been made:

Student Name / School

YES,MEETS ELIGIBILITY under McKinney-Vento requirements and qualifies for services from the PROGRAM (Insert school program name here) for the 2016-17 school year

NO,DOES NOT MEET ELIGIBILITY under McKinney-Vento requirements and does not qualify for services from the PROGRAM (Insert school program name here) for the 2016-17 school year because it was determined that the student has housing that is fixed, regular and adequate at this time

Based upon parent/youth’s wishes and best-interest determinations the following school placement is recommended:

Parent/Guardian/Youth request for school:
SCHOOL DISTRICT OFFER OF PLACEMENT
SCHOOL / GRADE / SCHOOL OF ORIGIN
RESIDENCE SCHOOL
Reason if NOT remaining in school of origin:

If you do not agree with this eligibility and/or placementdecision, you have the right to appeal and use the McKInney-Vento Dispute Resolution Form. During the appeal process, your child(ren) has the right to immediately enroll at the requested school(s) and participate in school activities. Please contact the school district homeless liaison (NAME and CONTACT INFO) and complete the McKinney-Vento Dispute Resolution Form

Signature of District Employee / Date

If remaining in the school of origin, please note the following:

• Transportation will be provided, if needed and requested, to remain in the school of origin.
• Students can remain in the school of origin for the school year as long as it continues to be in their best interest. Regular school attendance is one of the primary factors used in reviewing best interest so you may need to contact the PROGRAM if you need assistance or need to change transportation at any point in the year
• Attendance will be reviewed at the end of every quarter. If attendance is not satisfactory or there are excessive tardies or early dismissals that cannot be remedied, the student may have to transfer to the school in the attendance area you are temporarily residing in.
• Families must complete new paperwork every year for the PROGRAM. Eligibility and placement decisions do not carry over from one year to the next

SAMPLE DISPUTE FORMS (Forms E-G)

SAMPLE SCHOOL DISTRICT
DISPUTE FORM FORM E (Parent completes only if filing a dispute)

Date:

PARENT/GUARDIAN/STUDENT: If you have received the Parent/Guardian Notification of McKinney-Vento Eligibility and Placementletter from the school and you disagree with the decision that has been made, please complete the information below. A representative from the DISTRICT Homeless Education Program will contact you within (2) school days to obtain additional information and to work on resolving the dispute (within 5 school days).

Today’s Date:

Student Name: / Birthdate:
School: / Grade:
Parent/Guardian Name: / Phone #:

I disagree with the eligibility determination that was made by the school district

I disagree with the school placement decision that was made by the school district

Other: I disagree with ______

Name of person completing the form: / Signature
Relationship to student: / Contact #
Contact Mailing Address:

DISTRICT ONLY:

Date Received: ______

SAMPLE SCHOOL DISTRICT
McKinney-Vento DISPUTE RESOLUTION PROCESS NOTES FORM F (Liaison completes)

Date Dispute form received:______

Today’s Date: ______Dispute Resolution Deadline: ______

Nature of Dispute:

Eligibility determination

School placement decision

Other

List all students involved in dispute:

Student Name / Birthdate / School / Grade
Parent/Guardian Name: / Contact #
Contact Address

Notes:

Concern:
Next Steps
Resolution

If not resolved, date sent to COE Liaison ______

SAMPLE SCHOOL DISTRICT
McKinney-Vento DISPUTE RESOLUTION APPEAL LETTER FORM G (Liaison completes & send to parent)

[Insert Letterhead]

[Date]

[Address]

Re: Dispute of McKinney-Vento Homeless Education Assistance Act of 2001

Dear [Name]:

Please let this letter serve as response to you, as you assert your educational rights to dispute the district’s decision in regards to the eligibility and enrollment of your children under McKinney-Vento Homeless Education Assistance Act of 2001. Your children have a right to be enrolled in the school of selection until the dispute is resolved. School of selection is defined as the school of origin and/or school of residence. The district has made the determination that the family is no longer homeless for the following reasons:

• [Insert reasons and interventions]
• [Insert details and processes that occurred]

Under dispute resolution process, you have five (5) business days to provide evidence to negate the above reasons. It is important for me to remind you that the intent of the McKinney-Vento Homeless Education Assistance Act is to provide educational stability for homeless children and youth and it may be in the children’s best interest and stability to start the school year at their district of residence.

After the review of your documentation and appeal, the district will provide a written explanation, within five (5) business days, of the district's decision regarding school selection or enrollment. The letter will also include the right to appeal to the county office of education (COE).

If you wish to appeal the district’s decision, then you will have another five (5) business days to appeal to the COE’s homeless liaison. At that point, the district homeless liaison shall forward all written documentation and related paperwork to the COE’s homeless liaison. The COE's homeless liaison will review the materials from the district, as well as from you. They will then determine the school selection or enrollment decision within five (5) working days of receipt of the district and your materials. The COE homeless liaison will notify the LEA and parent of the decision. Please note that all the while this process is in place, your children will be enrolled in the school of selection. Please send your appeal and any pertinent information to:

[Insert COE’s Homeless Liaison’s Information]

I have enclosed a copy of California Department of Education’s Homeless Education Dispute Resolution Process, as well as other pertinent documentation to support the above reasons.

Instructions for Dispute Resolution

Parents, guardians, and unaccompanied youth must be able to initiate the dispute resolution process either in writing or orally directly at the selected school site.

II. Dispute Resolution Process

Below are five components for resolving disputes regarding school selection and enrollment for homeless children and youth:

● If a dispute arises over school selection or enrollment, the child/youth must be immediately enrolled in the school in which he/sheis seeking enrollment, pending resolution of the dispute [PL 107-110, Section 722(g)(3)(E)(iv)]. Enrollment is defined as "attending classes and participating fully in school activities."

● The school must refer the student, parent, or guardian to the LEA's homeless liaison to carry out the dispute resolution process as expeditiously as possible. The homeless liaison must ensure that the dispute resolution process is also followed for unaccompanied youth.

● A written explanation of the school's decision regarding school selection or enrollment must be provided if a parent, guardian, or unaccompanied youth disputes such a school selection or enrollment decision, including the right to appeal [PL 107-110, §722(g)(3)(E)(ii)]. The written explanation shall be complete, as brief as possible, simply stated, and provided in a language that the parent, guardian, or unaccompanied youth can understand.

• If the dispute remains unresolved at the district level or is appealed, then the district homeless liaison shall forward all written

documentation and related paperwork to the homeless liaison at the county office of education (COE). The COE's homeless

liaison will review these materials and determine the school selection or enrollment decision within five (5) working days of receipt of the materials. The COE homeless liaison will notify the LEA and parent of the decision. Please see the contact information for COE's homeless liaisons.

● If the dispute remains unresolved or is appealed, the COE homeless liaison shall forward all written documentation and related

paperwork to the State Homeless Coordinator. Upon the review of the LEA, COE, and parent information, the CDE will notify theparent of the final school selection or enrollment decision within ten (10) working days of receipt of materials. You may reach the State Homeless Coordinator, Leanne Wheeler, by phone at 916-319-0383 or by e-mail at .

School districts must enroll students experiencing homelessness immediately. If, after enrollment, it is determined that a student is not homeless as defined in the law, school districts should follow the policies that are in place to address other forms of fraud. Written notice should be given to the parent, guardian, or youth, including his or her right to appeal the decision.

III. California Department of Education's Recommendations

LEAs working with parents, guardians, and unaccompanied youth should:

● Inform parents, guardians, and unaccompanied youth that they can provide written or oral documentation to support their positions about school selection or enrollment.

● Inform parents, guardians, and unaccompanied youth that they can seek the assistance of social services, advocates, and/or

service providers in the dispute process.

● Provide a simple dispute form that parents, guardians, or unaccompanied youth can complete and turn in to the school to initiate the dispute resolution process.

● Provide a copy to the parents, guardians, or youth for their records when the dispute form is submitted to the school.

● Provide a copy to the parents, guardians, or youth for their records of the outcome of the dispute, even when the dispute is

immediately resolved satisfactorily without a dispute hearing.

Disclaimer: Recommendation to consult with legal counsel to determine how this document may apply to your specific facts and circumstances FCSS 12-01-17