Homelessness Verification Form for School Enrollment
Student Information
Student Name
Date of Birth
Current School (if any)
Grade
Parent / Guardian Information
Parent/Guardian Name
Relationship to Student
Contact Phone
Email Address
Current Living Situation
Living in emergency or transitional shelter
Temporarily in a motel/hotel/car/campground
Sharing housing due to loss of housing or economic hardship
Unsheltered or in a place not designed for sleeping
Other (please specify)
If other, please specify
Current Address (if available)
Address
City
State
Zip Code
Additional Student Needs
Please describe any immediate needs for the student (transportation, meals, supplies, etc.)
Verification & Signature
By signing below, I affirm that the information provided is accurate to the best of my knowledge and that the above-named student qualifies under the McKinney-Vento Homeless Assistance Act for school enrollment and services.
Parent/Guardian Signature
Date
School Liaison / District Representative Signature
Date