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Run: Homeless Student (McKinney-Vento) Eligibility and Services Form

This Homeless Student (McKinney-Vento) Eligibility and Services Form records eligibility, enrollment needs, transportation, and support services so a student...

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Submission Notice and Privacy Disclosure

I understand this form is used to review McKinney-Vento eligibility and document school supports. (required)

Yes No N/A

Consent to collect and use the information provided for eligibility review and service coordination (required)

By submitting, you consent to the collection and use of the minimum necessary PII for school enrollment, transportation, and support coordination.

Yes No N/A

Request anonymous submission for initial concern reporting

Select only if you want to submit a concern without identifying the student initially. A follow-up may be needed to complete eligibility review.

Yes No N/A

Submitter role (required)

Student and Case Identification

Student full name (required)

Student date of birth

Provide only if needed to match the student record.

Student ID

Optional if the student already has a district ID.

Current or requested school (required)

Grade level (required)

Case open date (required)

McKinney-Vento Eligibility Review

Current housing situation (required)

Is the student an unaccompanied youth? (required)

Eligibility basis (required)

Eligibility determination (required)

Determination notes

Record only objective facts needed for the audit trail and case review. Avoid unnecessary personal details.

Enrollment and School Stability Supports

Immediate enrollment support needed (required)

Records or documents needed for enrollment

School of origin requested (required)

School stability supports needed

Transportation and Service Plan

Transportation to school of origin needed (required)

Transportation mode

Transportation start date

Additional services requested

Review, Sign-Off, and Audit Trail

McKinney-Vento liaison name (required)

Review date (required)

Decision summary (required)

Summarize the eligibility decision and the supports approved.

Parent/guardian or youth signature

Use when signature is available and appropriate.

Staff signature (required)

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Email (required)

Your name (optional)

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