What is your current housing situation? Rent Own Other if this is checked, please complete the attached Housing Questionnaire – How did you learn about our program? Check all that apply: Website Site staff Community Past parent Flyer Community agency/Case worker Please specify: – Media Other Please specify: – Word of I have answered the questions to the best of my knowledge and have provided the requested documentation that I have available. Parent/Guardian Signature: Date (Month/Day/Year): Housing Questionnaire If you own/rent your home, you do not need to complete this form. The answers to the following questions can help determine the services this student may be eligible to receive. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. (Please see the next page for more information) If you do not own/rent your home, please share your current living situation. Check all that apply below: In a motel In a residence with inadequate facilities (no water, heat, In a shelter electricity, etc.) In someone else’s house or apartment with another Moving from to place/couch surfing family Please check one: A car, park, campsite, or similar location – By choice Transitional Housing Due to loss of housing, economic hardship, Other Please describe: – or similar reason STAFF: Review the ERSEA Procedure for follow up questions. Name of child (First, Middle, Last): Birthdate (Month/Day/Year): Gender: Child is unaccompanied (not living with a parent or legal guardian) Child is living with a parent or legal guardian Address of current residence: Phone Number: Name of contact: I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct.
What is your current housing situation? Rent Own Other – if this is checked, please complete the attached Housing Questionnaire How did you learn about our program? Check all that apply: Website Community Flyer Media Word of Site staff Past parent Community agency/Case worker – Please specify: Other – Please specify: I have answered the questions to the best of my knowledge and have provided the requested documentation that I have available. Parent/Guardian Signature: Date (Month/Day/Year): Housing Questionnaire If you own/rent your home, you do not need to complete this form. The answers to the following questions can help determine the services this student may be eligible to receive. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. (Please see the next page for more information) If you do not own/rent your home, please share your current living situation. Check all that apply below: In a motel In a shelter In someone else’s house or apartment with another family – Please check one: By choice Due to loss of housing, economic hardship, or similar reason In a residence with inadequate facilities (no water, heat, electricity, etc.) Moving from to place/couch surfing A car, park, campsite, or similar location Transitional Housing Other – Please describe: STAFF: Review the ERSEA Procedure for follow up questions. Name of child (First, Middle, Last): Birthdate (Month/Day/Year): Gender: Child is unaccompanied (not living with a parent or legal guardian) Child is living with a parent or legal guardian Address of current residence: Phone Number: Name of contact: I declare under penalty of perjury under the laws of the State of Washington that the information provided here is true and correct.
08.001.94_Expectant_Mother_Application_2018_-_2019_-_ADA_Version.docx