Housing Questionnaire / Needs Assessment Intake Form

Bremerton School District~McKinney-Vento Program

Housing Questionnaire / Needs Assessment Intake Form

Student Name (legal name):
Parent/Guardian/Foster Name:
Address:
Phone Number:
School: Grade:
Date: Gender: ☐ Male ☐ Female

Your child may be eligible for additional educational services through Title I, Part A and/or Title X, Part C, Federal McKinney-Vento Assistance Act. 42 U.S.C. 11435. Eligibility can be determined by completing this questionnaire.

Where are you and your family currently staying? Check one box.

Section A
☐ Rent/own my own home.
Section B(if any of the below apply pleasecomplete the Needs Assessment Form on back)
☐ Temporarily living with another person due to loss of housing, economic hardship or similar reason.
☐ Living with an adult that is not a parent or legal guardian, or alone without an adult.
☐ Hotel/motel.
☐ Unsheltered, living in a vehicle of any kind, park, campground, bus/train station, abandoned building, without running water/electricity,
abandoned in a hospital, or substandard housing.
☐ Emergency or transitional shelter, awaiting foster care.
☐ Other (living in an arrangement that is not fixed, regular, and adequate and is not described by the other choices).

If you checked a box in Section B complete page 2 (backside)

School Use Only

☐ Scan and email copy to Special Programs and CNS (Child Nutrition Services)

☐ Free Breakfast and Lunch available – inform parent/guardian

☐ McKinney-Vento Brochure available to parent/student or guardian

☐ Needs Assessment Intake Form – reviewed with family

☐ Transportation needed – Authorized by Special Programs ______

☐ NO LONGER HOMELESS – AS OF DATE:

Bremerton School District

Special Programs

Linda Sullivan-Dudzic, Special Programs Director and Homeless Liaison

Form A 6/2015 (360) 473-1077 - Fax (360) 473-1043

Page 2

Needs Assessment Intake Form(complete if McKinney Vento eligible)

Student Name : Click here to enter text.
Please list siblings or other children in the home:
Siblings Name / Grade / Age / School (if not enrolled, please indicate)
Student’s living situation:
☐Shelter☐Doubled Up1☐Temporary Placement4
☐Unsheltered2☐Motel/Hotel☐Migrant
☐Unaccompanied Youth3☐Awaiting Foster Care☐Transitional Housing
1Sharing the housing of other persons due to loss of housing, economic hardship, or similar reason
2Living in a car, park, campsite, trailer park, bus/train station, abandoned building, abandoned hospital, or other location not ordinarily used as sleeping accommodations
3Unaccompanied youth not living with a parent or guardian
4Child temporarily placed with relative or guardian
Is your current residence a temporary living situation?☐ Yes☐ No
Is your living arrangement due to the loss of housingor economic hardship?☐ Yes☐ No
I would like information on the following:
☐Free breakfast/lunch☐Tutoring – Title I/LAP
☐Headstart☐Before school programs – Elementary Schools
☐Clothing/Uniform☐Teen Center
☐School supplies☐Mentoring
☐Counseling☐Special Education
☐Medical/dental referral☐After school programs
☐Vision referral☐Vocational/technical
☐Medicaid/DSHS services – food stamps☐Community resource
☐Preschool Enrollment records☐ELL/Bilingual program
☐Missing enrollment records☐ Access to Child Care
☐ Birth certificate ☐Prior academic records
☐ Immunization/medical records ☐TRANSPORTATION ______
☐Other ______

Parent/Guardian/Unaccompanied Youth SignatureDate

Form A 6/2015