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Todacheene bie. edu Phone 505. 563. 5269 Page 1 SAMPLE This document is intended to address the McKinney-Vento Act. Your answers will help the administrator determine residency documents necessary for enrollment of this student. Presently where is the student living Check one box Section A in a shelter with more than one family in a house or Apartment in a motel car or campsite with friends or family members other than parent/guardian CONTINUE if you checked a box in Section A complete 2 and the remainder of this form Choices in Section A do not apply STOP If you checked this section you do not need to complete the remainder of this form. Submit to school personnel The student lives with 1 parent 2 parents 1 parent another adult a relative friend s or other adult s alone with no adults an adult that is not the parent or the legal guardian School Male Name of Student Birth Date / Age Female Social Security if appropriate Name of Parent s /Legal Guardian s Address Zip Signature of Parent/Legal Guardian Phone Date School Use Only School Administrator s determination of Section A circumstances If the parent has checked Section B above completion of form is not required. For any choices in Section A this form must be completed and provided to School Registrar immediately after completion. Form will be kept separately from the Student Permanent Record for audit purposes during the year. BIE-McKinney-Vento Student Residency Verification Document The document on page 2 is a sample for schools to consider utilizing in addressing the requirements of the McKinney-Vento Act Title X Part C of NCLB. This document can be included in the School Enrollment Packet at the beginning of the school year for parent s /guardians of student s to complete. A determination will be made by the school if the student is eligible to receive services under the McKinney-Vento Act based on how the parent s /guardian s respond to the information in the document. In addition living situations may change any time within the school year therefore it is recommended that this document be distributed again at the end of the school year. Identifying students in homeless situation s is critical and schools must make considerable effort to the identification and providing services to students in a homeless situation according to the McKinney Vento Act. If you would like additional information please contact Dr. Valerie Todacheene Education Program Specialist/BIE McKinney Vento State Coordinator E-mail Valerie. Todacheene bie. edu Phone 505. 563. 5269 Page 1 SAMPLE This document is intended to address the McKinney-Vento Act. Your answers will help the administrator determine residency documents necessary for enrollment of this student. Presently where is the student living Check one box Section A in a shelter with more than one family in a house or Apartment in a motel car or campsite with friends or family members other than parent/guardian CONTINUE if you checked a box in Section A complete 2 and the remainder of this form Choices in Section A do not apply STOP If you checked this section you do not need to complete the remainder of this form* Submit to school personnel The student lives with 1 parent 2 parents 1 parent another adult a relative friend s or other adult s alone with no adults an adult that is not the parent or the legal guardian School Male Name of Student Birth Date / Age Female Social Security if appropriate Name of Parent s /Legal Guardian s Address Zip Signature of Parent/Legal Guardian Phone Date School Use Only School Administrator s determination of Section A circumstances If the parent has checked Section B above completion of form is not required* For any choices in Section A this form must be completed and provided to School Registrar immediately after completion* Form will be kept separately from the Student Permanent Record for audit purposes during the year..

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