Form - Temporary Residence Statement

This forms helps determine eligibility under the federal McKinney-Vento Act. Only 1 form per FAMILY needed.

Name of Students:

Name of Parent/Guardian/Caretaker(write N/A if unavailable):

The student(s) temporarily stay(s) in one of the following situations: (required) Emergency shelter(Lacasa, The Connection, Local agency paying for motel/hotel) Transitional Housing Motel/Hotel(You're paying) Shares housing(doubled up or "couch surfing") with family or friends due to loss of housing, economic hardship or similar reasons such as family conflict, unhealthy living conditions, unsafe situation Substandard housing, campground; public or private place not designed for or ordinarily used as regular sleeping accommodation for humans, including cars, parks, public spaces, abandoned buildings, bu Another situation that is not fixed, regular, or adequate.

The reason for this living situation is: (required) Unemployment Evicted Inadequate Income Fire/Natural disaster Kicked Out Family Conflict Unsafe Conditions Other

I/We have been living at this temporary address:

Since this date:

For minor unaccompanied youth ONLY(age 17 and under):

By selecting; I Agree, you understand that you are eligible to receive support from your school district and local community agencies through the McKinney-Vento Act. You also understand that you can contact your school liaison if you need anything throughout the school year. I Agree I Disagree

For Parents, Caregivers or Unaccompanied Youth over 18, by agreeing to each each paragraph below you are acknowledging your understandings of each paragraph.

I declare that the information provided here is true and correct and of my own personal knowledge. I understand that falsifying resident information for the purposes of school enrollment is against Michigan law. Falsifying enrollment information is an offense subject to prosecution I Agree I Disagree

The Education Project Staff respects a client's right to privacy. To ensure the best services possible and compliance with the federal law and state grant data reporting requirements, I give my permission to the Education Project staff to release and exchange information with contractors working alongside The Education Project, school staff(i.e. the McKinney-Vento Liaison, pupil accounting, school transportation staff, school social workers. counselors, etc.) and community agencies that are assisting the student(s) or being asked to assist the student(s) as needed. This consent is voluntary and subject to revocation at any time. I Agree I Disagree

I understand that this consent is valid for the remainder of the school year and I that I will receive a copy and an explanation of the student's right under the McKinney Vento Act. I Agree I Disagree

Name of person filling out this form:

Relationship to student(s):

Date of form completion:

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Temporary Residence Statement