2025-2026 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 for "Student(s) Name"

Grade Level*

Answer required for "Grade Level"

Date of Birth*

Answer required for "Date of Birth"

School*

Answer required for "School"

All other children under age 18 living in the home

Student(s) Name

Answer required for "Student(s) Name"

Grade Level

Answer required for "Grade Level"

Date of Birth

Answer required for "Date of Birth"

School/District

Answer required for "School/District"

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

Answer required for "Where is your child/family currently staying? (Check ONE box)"

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

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

Answer required for "If you chose motel, what is the name of the motel/adress/room#"

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

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

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 for "Relationship to child(ren)"

Parent(s)

Friend(s)

Family Relative

An adult who is not the Legal Guardian

Unaccompanied Youth

Residence Address

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Telephone/Text Number*

Number Required

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

Answer required for "Does the address/telephone need to be updated in our systems?"

Yes

Robla New Hope Charter School

Please fix the highlighted areas below before submitting.

2025-2026 Housing Questionnaire