West Virginia Academy's

Student Housing Questionnaire

The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness (Please see reverse side for more information).

If the student lives in a home owned or rented by the parent or guardian, you do not need to complete this form unless there are inadequate facilities (no water, heat, electricity, etc.)

If the student does not live in a home owned or rented by the parent or guardian, please check all that apply below. (Submit form to the Student Success Office.)

Transitional Housing

In someone else’s house or apartment with another person/family

In a residence with inadequate facilities (no water, heat, electricity, etc.)

In a motel

Moving from place to place/couch surfing

In a shelter

A car, park, campsite, or similar location

Other___________________

First name

Last name

Birthday

Gender

Male

Female

Grade in school

Guardianship

Student is unaccompanied (not living with a parent or legal guardian)

Student is living with a parent or legal guardian

Address of current residence

Phone

Name of Contact

Print name of parent(s)/legal guardian(s) or unaccompanied youth:

Signature of parent/legal guardian or unaccompanied youth

Date

The student(s) named above have younger siblings/children (not yet school age) who are in need of developmental screening, community support, or referrals to early childhood services. The district’s McKinney-Vento liaison may be able to assist you with age-appropriate resources.

Please click NEXT at the bottom of this form, you will be taken to an informational sheet where you can submit at the bottom.

FOR SCHOOL USE ONLY: For data collection purposes and student information system coding

Multi choice

Student Housing Questionnaire

Please click NEXT at the bottom of this form, you will be taken to an informational sheet where you can submit at the bottom.

Join our mailing list