Date:__________________

Person Making Referral:_________________________________________________Position:______________________

School/Agency:_____________________________________________________________________________________

Address:___________________________________________________________________________________________

Phone #:_______________________________ Email:______________________________________________________

STUDENT INFORMATION:

I have identified a student who may be experiencing homelessness (lacking a fixed, regular and adequate nighttime residence) and would like to make a referral to the District Liaison.

Student Name:______________________________________________________________________________________

School in Which Student was Last Enrolled:_______________________________________________________________

Grade Level:___________ Parent(s)/Guardian(s) Phone #:___________________________________________________

Parent/Guardian Name:______________________________________________________________________________

Parent/Guardian Address:_____________________________________________________________________________

Reason For Referral:	Support Services Needed:
 Shelter Resident  Shared Housing (Doubled Up)  Transitional Housing  Motel/Hotel Resident  Campground/Tent  Unaccompanied Youth (not in the physical custody of a parent or guardian and lacking a fixed, adequate, and regular nighttime residence).  Other	 Enrollment Assistance  Tutoring or Instructional Support  Transportation  School Supplies  Clothing  Other:________________________________________  Other:________________________________________  Other:________________________________________  Other:________________________________________

 

PARENT/GUARDIAN CONSENT FOR RELEASE OF INFORMATION:

·         I was notified about the McKinney-Vento rights and services my child may be eligible for in school.

·         I give permission for ________________________________________ to share my living situation to the District Liaison in order to learn more about what supports and services my child may be eligible for while our housing is in transition.

·         No information about my child’s health, medical needs, mental health or domestic violence will be shared unless I sign a separate release of information.

Parent/Guardian Signature:____________________________________________________________________________

Relationship to Student:______________________________________________________________________________

Phone # where I can be Reached:_____________________________________________ Date:_____________________

Adopted:  01/21/20