Student Residency Questionnaire Monahans-Wickett-Pyote Independent School District Cullender Kindergarten PART I Name of Student: ____________________________________________________________ Sex:  Male Last First Middle  Female Birth Date

/ Month

/

Age: _________

Social Security #: ___________________________

/ Day / Year

(or student identification number)

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11434a(2). The answers to this residency information help determine the services the student may be eligible to receive. 1.

Is your current address a temporary living arrangement?

_____ Yes

2.

Is this temporary living arrangement due to loss of housing or economic hardship? _____ Yes

_____ No

_____ No

If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here. PART II Where is the student presently living? (Check one box.)     

In a motel In a shelter With more than one family in a house or apartment Moving from place to place In a place not designed for ordinary sleeping accommodations such as a car, park, or campsite

Name of Parent(s)/Legal Guardians(s) __________________________________________________________ Address________________________________________________ Zip __________ Phone_______________ Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the child under false documents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3)(d).

Signature of Parent/Legal Guardian________________________________________ Date______________ PART III I certify the above named student qualifies for the Child Nutrition Program under the provisions of the McKinney-Vento Act. __________________________ Date

_____________________________________________________ McKinney-Vento Liaison Signature

For office use only: Is this a new student? If yes, proceed with district identification questions. Is this a new situation for this student? If yes, proceed with district identification questions. Forward positive indications to the administration office. 8/2015

Cuestionario de Residencia para Estudiantes Monahans-Wickett-Pyote Independent School District Cullender Kindergarten La sección uno Nombre del Estudiante ____________________________________________________ Sexo:  Masculino Apellido Nombre Segundo Nombre  Femenino Fecha de Nacimiento _____/_____/______ Edad: ______ # de Seguro Social: _________________________ Mes

Día

Año

(o número de indentificación escolar)

El propósito de este cuestionario es presentar los objetivos del Acta McKinney-Vento (42 U.S.C.11434a(2)). Las respuestas a estas preguntas ayudarán determinar los servicios que el estudiante debe recibir. 1. ¿Es su domicilio actual un arreglo de vivienda temporal (de poca duración)?

_____Si`

_____ No

2. ¿Es este arreglo de vivienda temporal debido a la pérdida de su casa, vivienda o habitación, o debido a algún problema económico (ejemplo: desempleo)? _____S`

_____ No

Si usted contestó SI a estas preguntas, por favor complete el resto de este formulario. Si usted contestó NO a estas preguntas, no siga. La sección dos ¿Dónde se encuentra viviendo el estudiante actualmente? (Marque una opción.)     

En un motel En un albergue o lugar de refugio Con más de una familia en una casa o apartamento Moviéndose de lugar en lugar En un lugar generalmente no designado para dormir (ejemplo: carro, parque, o campamento)

Nombre del Padre/Madre/Guardián_____________________________________________________________ Dirección ______________________________________ Zona Postal _________ Teléfono ______________ Presentar información falsa o la falsificación de documentos para uso escolar son ofensas bajo la Sección 37.10 del Código Penal, y la inscripción del estudiante usando documentos falsos traerá como consecuencia que los responsables estarán sujetos a pagar los gastos de instrucción u otros cargos. TEC Sec. 25.002(3)(d).

Firma del Padre/Madre/Guardián_________________________________________ Fecha _____________ La sección tres Yo certifico que el estudiante nombrado en este formulario califica para los programas de nutrición escolares bajo las provisiones del Acta McKinney-Vento. ___________________________ Fecha

______________________________________________________ Firma del oficial autorizado

8/2015

Student Residency Questionnaire Monahans-Wickett-Pyote Independent School District Instructions-Compliance tied to Title I Schoolwide Programs THIS IS A CONFIDENTIAL, FEDERAL PROCESS Please read and completely follow the directions for the Student Residency Questionnaire. 1. 2. 3. 4.

Provide a questionnaire to every new student enrolling in the district at the beginning of school. Provide a questionnaire to every student with an address change at the beginning of school. Provide a questionnaire to any student with a change of address during the school year if you have reason to believe they are moving to a status which meets the federal definition for homelessness. Provide a questionnaire to all students listed for McKinney-Vento from the previous year to re-evaluate status.

PART I-to be completed by the parent or guardian 1. 2. 3. 4. 5.

Collect all questionnaires and review the contents. Check answers in the first section. If both questions are answered “yes” the remainder of the form must be completed or it will need to be returned to the parent or guardian for completion. If question one is “yes” but question two is “no”, file the form for ****5 year retention. If question one is “no” but question two is “yes” ask additional clarifying questions to determine status. File the form for ****5 year retention****.

PART II-to be completed by the parent or guardian if needed. 1. 2. 3.

Complete this section if parent answers meet the qualification in Part I based upon your questioning. At least one box must be checked. Ask clarifying questions if not. Name and address of parents should be filled in unless the student is over 18. The legal age student may sign and/or identify status for him/her self.

PART III-to be completed by the Office of the District McKinney-Vento Liaison 1. 2.

If all questions indicate a student is indeed homeless, please forward the questionnaire to the Office of the McKinney-Vento Liaison for the district. The office will review the questionnaire and determine status.

OR 3. 4. 5.

If the liaison is not certain, form will be returned for more information determined by clarifying questioning if needed. The District Liaison will date, sign, and return the form to the campus. If the note is returned, one of two actions must occur. a. The form is incomplete or uncertain as to clear status and an interview must be conducted by the campus before returning the form to the office. OR b. The form is complete and the office will complete the identification process.

IDENTIFICATION PROCESS COMPLETION 1. 2. 3. 4. 5. 6.

The form arrives back at the campus signed and dated by the District McKinney-Vento Liaison. Form is placed in the active McKinney-Vento file if the student is identified as “homeless”. Appropriate services documentation begins and is placed in the file also. Each teacher receives a copy. The Campus Liaison refers the student’s name to the PEIMS clerk and the student is entered into the system for the YEAR. Campus notifies the District Cafeteria Manager of the status. Status may change at any time BUT the student remains identified until the beginning of the next year. The process then will begin a new cycle to re-identify the student as meeting homeless status or not. ALL FORMS ARE RETAINED ON A 5 YEAR SCHEDULE and filed.

*****Change in procedure. All filled out surveys will be returned to you for record retention of 5 years. Campus must keep a roster of McKinney-Vento identified students to be turned in before the Campus Liaison may check out for the summer. This list should be delivered or emailed to the District Mc-V Liaison.

8/2015