McKinney-Vento Housing Questionnaire

The answers to the following questions help determine services a student may be eligible to receive under the McKinney-Vento Act. This program supports children and youth experiencing homelessness.

If you own or rent your own home, you do not need to complete this form.

If you do not own or rent your own home, please complete the questions below.

Current Living SituationSelect all that apply

In a motel

In a shelter

Moving from place to place / couch surfing

In someone else’s house or apartment with another family

In a residence with inadequate facilities (no water, heat, electricity, etc.)

In a car, park, campsite, or similar location

Transitional housing

Other

Select all that apply

Namerequired

First Name

Middle (optional)

Last Name

Birth Date

Must contain a date in MM/DD/YYYY format

Name of school

Grade

Gender

Student Status

Student is unaccompanied (not living with a parent or legal guardian)

Student is living with a parent or legal guardian

Address of current residence

Phone Number

Name of guardianrequired

First Name

Last Name

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