Souderton Area School District
Homeless Supports Residency/Housing Questionnaire
Parent/Guardian/Student:
This form is intended to address the McKinney-Vento Act 42 U.S.C. 11435, and must be completed for each
student. The information you provide is confidential. Your child will not be discriminated against based upon the
information provided.
Please complete the following questions regarding the student’s housing in order to help determine services
student may be eligible to receive.
Note to schools/homeless liaison: Please assist students and families in filling out this form. Do not simply include this
form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required
to submit proof of residency and other required documents that may be part of the registration packet.
Student Name
Last First Middle
PA Secure ID Date of Birth Gender School
Please identify the student’s current living arrangements. Please check one box:
Residency Questionnaire Choice
Double-Up
With another family or other person because of loss of housing or as a result of economic hardship
Shelter
Emergency or transitional shelter
Awaiting Foster Care Placement
Hotel/Motel
Living in what is NOT an emergency or transitional shelter and involves payment
Other Temporary Living Situation
Trailer park, campground, car, park, public places, abandoned building, street, or any other
inadequate living space
Permanent Housing
Student who is living in a fixed, regular, and adequate housing situation
If the student is NOT living in permanent housing, also indicate if the below applies:
Unaccompanied Youth
Youth who is not in the physical custody of a parent or guardian
Parent/Guardian Name (print) Parent/Guardian Signature Date
Please return this form to your child’s school as requested.
Note: The answer you give above will help determine what services you or your child may be eligible to receive under
the McKinney-Vento Act. Students who are protected under the Act are entitled to immediate enrollment in school even
if they do not have the documents normally needed, such as proof of residency, school records, immunization records, or
birth certificate.
