Code: JLG-E 3 MCKINNEY-VENTO REFERRAL TO DISTRICT LIAISON 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:_____________________________________________________________________________
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 |
Policies > J_STUDENTS >