STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT
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- Juan José Rivas Quintero
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2 STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT This document is intended to address the McKinney-Vento Assistance Act. Your answers will help determine documents necessary to enroll your child quickly and determine their eligibility for services. (Complete for all children from BIRTH to 18 years of age.) Student(s) Name(s) Student(s) Date(s) of Birth Grade School Parent/Guardian Name Parent/Guardian Phone (Day) Parent/Guardian Phone (Evening) Circle: Home/Work/Mobile Circle: Home/Work/Mobile Parent/Guardian Address (mailing) City Zip Emergency Phone Parent/Guardian Address (physical) Check if same as mailing City Zip Are the above-named students in the foster care system? (Circle one) YES NO Are the above-named students children of an active-duty U.S military member? (Circle one) YES NO I am the parent/guardian of this student and our current housing is: 1. Own, lease or rent an apartment, condo or house. YES STOP here and sign at the bottom of the form NO Continue to the next line 2. If you marked NO, what is your current living situation (check all that apply): an emergency shelter a transitional shelter a motel or hotel unsheltered (i.e.: cars, parks, garage, campgrounds) foster youth awaiting placement (in an emergency placement as defined by the social worker) unaccompanied youth not living with parent or guardian substandard housing *(describe: ) *(i.e. no water, no electricity) Due to loss of housing or economic hardship, we live with another family or friends Other: I declare under penalty of perjury under the laws of California that the foregoing information is true and correct. I would be competent to testify thereto. Signature of parent/guardian: Date Print your Name: Your relationship to the Student: (circle one) Parent/Step-parent Legal Guardian Foster Parent Relative Other: Residency Questionnaire (Rev. 4/13) File original form separately from the Student Permanent Cumulative Record
3 CUESTIONARIO DE RESIDENCIA ESTUDIANTIL Y DECLARACIÓN JURADA El objetivo de este documento es para tratar con la ley, McKinney-Vento Assistance Act. Sus respuestas ayudarán a determinar los documentos que se necesitarán para inscribir de inmediato a su hijo y establecerán su elegibilidad para recibir servicios. (Favor de llenar este formulario para todos sus hijos, desde recién nacidos hasta los 18 años de edad.) Nombre del alumno Fecha de nacimiento del alumno Grado escolar Escuela Nombre del padre de familia o el tutor legal Teléfono del padre de familia o el tutor legal (durante el día): Teléfono del padre de familia o el tutor legal (por la noche): Encierre en un círculo: Casa/ trabajo/celular Encierre en un círculo: Casa/ trabajo/celular Dirección (postal) del padre de familia o el tutor legal Ciudad Código postal Teléfono en caso de emergencia: Dirección (física) del padre de familia o del tutor legal marca si es la misma dirección de postal Ciudad Código postal Forman parte de un plan de cuidado de crianza (foster care) los niños anteriormente mencionados? (Encierren un círculo) SÍ NO Son hijos de un miembro activo del ejercito de EE.UU los niños anteriormente mencionados? (Encierren un círculo) SÍ NO Soy el padre de familia o el tutor legal de este alumno y actualmente nuestra residencia es: 1. Soy el dueño o alquilamos un apartamento, condominio o casa: SI DEJE DE LLENAR el cuestionario aquí y firme en la parte indicada al final. NO Sigua a la pregunta siguiente 2. Si indicó NO, cual es su residencia actualmente: (marque todas las respuestas correctas): Vivimos en un refugio de emergencia. Vivimos en un refugio transitorio. Vivimos en un motel u hotel. Vivimos en un lugar abierto o desprotegido al viento. (Ejemplos: En un carro, parque, garaje o campamento.) Tengo custodia de un joven en espera de una asignación de cuidado de crianza [foster care]. Un joven que no esté bajo la custodia legal de una persona adulta. Vivimos en una vivienda inadecuada. (*Describa: ) (*Ejemplos: No hay agua; no hay electricidad.) Debido a la falta de vivienda o por cuestiones económicas, vivimos con otra familia o con amigos Otro: Declaro bajo pena de perjurio, conforme a las leyes del Estado de California, que la información anteriormente indicada es fiel y exacta. Estoy legalmente capacitado para dar fe a esto. Firma del padre de familia o el tutor legal: Fecha Favor de escribir su nombre en letra de molde: Su parentesco al alumno: (Encierre en un círculo la respuesta.) Padre o madre Padrastro o madrastra Tutor(a) legal Padre o madre de crianza (Foster Parent) Pariente Otra relación: Residency Questionnaire (Rev. 4/13) File original form separately from the Student Permanent Cumulative Record
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