Norwalk: Housing Questionnaire

YouthBuild Charter School of California Housing Questionnaire - Norwalk
Student's Last Name:
First Name:
Middle Name:
The information provided below will help the LEA determine what services you and/or your child may be eligible to receive. This could include additional educational services through Title I, Part A and/or the federal McKinney-Vento Assistance Act. The information provided on this form will be kept confidential and only shared with appropriate school district and site staff.
Presently, are you and/or your family living in any of the following situations? Check all that apply.
The undersigned parent/guardian certifies that the information provided above is correct and accurate.
Parent/Guardian's Name (if student is under 18) or Adult Student's Name (if student is 18+)
Signature of Parent/Guardian or Adult Student:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip
Your child or children may have the right to:
1. Immediate enrollment in the school they last attended (school of origin) or the local school where you are currently staying, even if you do not have all the documents normally required at the time of enrollment.
2. Continue to attend their school of origin, if requested by you and it is in the best interest.
3. Receive transportation to and from their school of origin, the same special programs and services, if needed, as provided to all other children, including free meals and Title I.
4. Receive the full protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families. Please list all children currently living with you.
If you have any questions about these rights. please contact the local homeless liaison, Tizoc Brenes, by phone at 213-741-2600 or by email at tbrenes@youthbuildcharter.org.
Please enter the information of all children currently living with you:
1st Child's Name:
Gender of 1st Child (M/F/NB)
Birthdate of 1st Child:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade of 1st Child:
Name of School 1st Child Attends:
Name of 2nd Child:
Gender of 2nd Child (M/F/NB):
Birthdate of 2nd Child:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade of 2nd Child:
Name of School 2nd Child Attends:
Name of 3rd Child:
Gender of 3rd Child (M/F/NB):
Birthdate of 3rd Child:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade of 3rd Child:
Name of School 3rd Child Attends:
Should be Empty:

YouthBuild Charter School of California Housing Questionnaire - Norwalk