2024-2025 Housing Questionnaire

This information will be used to determine if your child qualifies for any additional assistance under the McKinney-Vento program. Eligibility can be determined by completing this questionnaire

Student(s) Name*

Answer Required

Grade Level*

Answer Required

Date of Birth*

Answer Required

School*

Answer Required

All other children under age 18 living in the home

Student(s) Name

Answer Required

Grade Level

Answer Required

Date of Birth

Answer Required

School/District

Answer Required

Where is your child/family currently staying? (Check ONE box)*

Answer Required

Own home or renting a single-family residence with name on rental lease.

With more than one family in a house or apartment due to economic hardship.

In an emergency shelter or transitional housing program

In a motel

Unsheltered (i.e. car, camp site, outside, or a structure not intended for sleeping.)

Housing that is inadequate (ie: no electricity, running water, etc.)

In a foster care placement or group home

If you chose emergency shelter or transitional housing program, what is the name of the program/address

Answer Required

If you chose motel, what is the name of the motel/adress/room#

Answer Required

If you chose foster care placement or group home, what is the social worker's contact iinfo

Answer Required

Education Rights of Homeless Children

Immediate enrollment - Stay at school of origin if you move - Transportation support if you move - Receive full protections and services provided under all federal and state laws, as it relates to homeless chidlren.

Signature*

Signature Required

Relationship to child(ren)*

Answer Required

Parent(s)

Friend(s)

Family Relative

An adult who is not the Legal Guardian

Unaccompanied Youth

Residence Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Telephone/Text Number*

Number Required

Does the address/telephone need to be updated in our systems?

Answer Required

Yes

Robla New Hope Charter School

Please fix the highlighted areas below before submitting.

2024-2025 Housing Questionnaire