Phone Number: ________________________________
Email Address:
__________________________________________________________ _____________________________________
Olympia School District Student Housing Questionnaire
Answering the following questions help determine educational services your student may be eligible to receive under the
McKinney Vento Act 42 U.S.C 11435. The McKinney Vento Act provides services for children and youth experiencing
housing instability or homelessness. For more information, please see the reverse side.
If You Own or Rent an Apartment or House, You Do Not Need to Complete this Form
Student Name:
__________ Birthdate: Grade:
Please check all that apply to your student’s current living situation:
In a shelter
Moving from place to place/couch surfing
In a car, park campsite or similar location
Temporarily living with another person/family due to economic hardship and lack/loss of housing
Temporarily displaced due to fire, natural disaster, etc
In a residence with inadequate facilities (no water, heat, electricity, etc.)
In a motel or hotel due to lack of alternative accommodations & lack/loss of housing
Transitional housing
Who is the student living with?
Student is not living with a parent or legal guardian (Unaccompanied Youth)
Student is living with a parent or legal guardian
List all preschool and school-aged children living with you or related to the student (PLEASE PRINT CLEARLY)
Name: ___________________________ Birthdate: ______________ Current School: ____________________________
Name: ___________________________ Birthdate: ______________ Current School:
Name: ___________________________ Birthdate: ______________ Current School:
I require an interpreter in
(Primary Language)
Name of Parent/Legal Guardian/ Caretaker/ Unaccompanied Youth:
Current Nighttime Address:
Mailing Address:
Signature of Parent/Legal Guardian/Caretaker/Unaccompanied Youth
I declare under penalty of perjury under the laws of the State of Washington that the information provided is correct and true
Submit the completed form to OSD School Office, School Counselor or Leslie Gowell, OSD McKinney Vento Office,
OSD Admin Offices, 111 Bethel St., Olympia, WA. 98501 Email: lgowell@osd.wednet.edu or 360 596-6313
_____________________________Current School:
_________________________________________School Enrolling at:
McKinney-Vento Act 42 U.S.C. 11435
For purposes of this subtitle:
(1) The terms enroll' and enrollment' include attending classes and participating fully in school activities.
(2) The term homeless children and youths' —
(A) means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section
103(a)(1)); and
(B) includes —
(i) children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a
similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of
alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned
in hospitals;
(ii) children and youths who have a primary nighttime residence that is a public or private place not designed for or
ordinarily used as regular sleeping accommodation for human beings (within the meaning of section
(iii) children and youths who are living in cars, parks, public space s, abandoned buildings, substandard housing, bus
or train stations, or similar settings; and
(iv) migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of
1965) who qualify as homeless for the purposes of this subtitl e because the children are living in
circumstances described in clauses (i) through (iii).
(6) The term unaccompanied youth `` includes a youth, not in the physical custody of a parent or guardian.
Additional Resources
Student & Parent information and resources can be found at the following:
National Center for Homeless Education
National Association for the Education of Homeless Children and Youth (NAEHCY)
SchoolHouse Connection