Documentation of Residency Through Home Visit
Office of Student and Family Support and Engagement
International Admissions and Enrollment (IAE)
MONTGOMERY COUNTY PUBLIC SCHOOLS (MCPS)
Rockville, Maryland 20850
PART I: Student Information
Student Name(s) _______________________________________________________________________________ Student ID(s) _______________
_______________________________________________________________________________ Student ID(s) _______________
Date of Home Visit
____/____/_____
Time of Home Visit
____:____ o a.m. o p.m.
School
________________________________________________________________________________________________________________
Parent(s)/Guardian(s) Name(s) __________________________________________________________________________________________
Address on Record _____________________________________________________________________________________________________
Address Visited (if different) _____________________________________________________________________________________________
Home Phone _____-_____-______ Work Phone _____-_____-______ Cell Phone _____-_____-______
Name of siblings who attend MCPS:
Name
_______________________________________ Student ID #_______________ School_____________________________________
Name _______________________________________ Student ID #_______________ School_____________________________________
Name _______________________________________ Student ID #_______________ School_____________________________________
Sibling(s) schools(s) contacted? o Yes o No Other Pupil Personnel Workers (PPWs) contacted? o Yes o No
What initiated the request for the home visit?
_____________________________________________________________________________
PART II: Results of Home Visit (check all that apply)
o Observation of parent/guardian in residence at time of visit
o
Consultation with homeowner, renter, or property management staff
o Consultation with neighbors
o Viewed living space of family (i.e., kitchen, bathrooms, bedrooms, etc.)
o Property appears vacant
o No answer at the residence
o Door Hanger left
o Other ______________________________________________________________________________________________________________
Notes/Additional Comments
o Additional documentation collected from parent/guardian at time of visit
o Additional documentation provided to parent/guardian at time of visit
Comments:
o Residency NOT confirmed
o Residency confirmed
Recommendation(s) for next steps:
PART III: SIGNATURES
Name of PPW (printed)
___________________________________ Signature of PPW _______________________Date _____/_____/______
Other MCPS Staff Name(s) Participating in Home Visit (printed)
_____________________________________________________________
Signature of Other MCPS Staff Participating in Home Visit ____________________________________________ Date _____/_____/______
Signature of Other MCPS Staff Participating in Home Visit
____________________________________________ Date _____/_____/______
DISTRIBUTION: COPY 1/Student Cumulative Folder; COPY 2/IAE; COPY 3/PPW
MCPS Form 560-34
July 2018
