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McKinney Vento Student Referral Form
This Student Referral Form must be filled out for
each student
being referred.
THE EDUCATION PROJECT: Support and Advocacy for Livingston County Students who are homeless or in transition.
STUDENT REFERRAL FORM
Date
Referral Contact & Agency: Kristin Rosalez
Referral Phone Number: 517-223-6014
Student's First Name
Student's Last Name
Date of Birth
Grade Level
(Please Select)
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Special Education/IEP/504
(required)
Yes
No
Needs Evaluation
Not Sure
School District Where Currently Enrolled
Date Started School
Student is Participating in
(required)
CTE
Early College
English Language Learner
Not Applicable
Is the student living with a parent/guardian?
(required)
Yes
No
If Yes, what is the parent/guardian's name?
If Yes, what is the parent/guardian's phone number?
If Yes, what is the parent/guardian's email address?
If No, what is the student's phone number?
Is the parent/guardian a veteran?
(required)
Yes
No
What district did the student previously attend?
How many siblings (living with student) are ages Birth - 2 years old (NOT in Early Head Start)?
How many siblings (living with student) are 3-5 years old (NOT in Head Start, GSRP, Kindergarten)?
How many siblings (living with student) are in Early Head Start?
How many siblings (living with student) are in Head Start/GSRP?
How many siblings (living with student) are in Elementary School (K-5)?
How many siblings (living with student) are in Middle School (6-8)?
How many siblings (living with student) are in High School (9-12)?
First & Last Name of siblings (living with student) and school attending (if applicable):
Services Needed
Backpack
Backpack color preference
School Supplies
Include specific supplies needed
Clothing
Winter
Summer
Both
Types of clothing needed and sizes
Socks
Sock Size
Underwear
Underwear size
Shoes
Shoe size
Winter Gloves
Winter Glove size
Winter Hat
Winter Hat size
Winter Boots
Winter Boot size
Winter Coat
Winter Coat size
Hygiene Kit
Food
Laundry Kit
Laundry Vouchers
Extra-Curricular Activities
Field Trips
Academic-related expenses
Graduation Costs
Holiday gift program
Free/Reduced School Breakfast/Lunch
Community Referrals
Transportation Needed
Yes
No
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