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Olympia School District Student Housing Questionnaire
ARE YOU EXPERIENCING HOUSING INSTABILITY?
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
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List all preschool and school-aged children living with you or related to the student (PLEASE PRINT CLEARLY)
Name: ___________________________ Birthdate: ______________ Current School: ____________________________
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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:
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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: