MIS 6341

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School District of Okaloosa County

Quality Assurance

TITLE X, PART C – TRANSPORTATION DOCUMENTATION

Reference:

1.  The McKinney-Vento Homeless Assistance Act, 42 U.S.C. 11431 – 11436.

2.  Stewart B. McKinney-Bruce Vento Homeless Assistance Act, PL 107-110, Title X – Part C, Section 722.

3.  Title I, Part A of the Elementary and Secondary Education Act, 20 U.S.C. 6311 – 6315.

4.  The Individuals with Disabilities Education Act, 20 U.S.C. 1400 et.seq.

5.  April 6, 2002 policy of the Child Nutrition Division of the U.S. Department of Agriculture.

6.  June 5, 1992 Policy of the Administration for Children and Families of the U.S. Department of Health and Human Services.

7.  Chapter 1003: 1003.01(12), 1003.21(f), 1003.22(g), Public K-12 Education, Florida Statutes.

On behalf of the District Liaison for Homeless Children and Youth, I certify that the child(ren) identified below meet the definition of homelessness and defined by Title X, Part C of the McKinney-Vento Homeless Education Act are eligible for transportation and attendance at the school of origin outside of the established zoned school where the student currently resides. (School or origin is defined as the school that the child attended when permanently housed or the school in which the child was last enrolled.)

Child(ren)’s Name / School of Origin Name / Grade / School ID Number

Parent Name: ______Phone or Cell Number______

Current Address: ______

Effective Date: ______

Duration: ______

MIS 6341

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Residence Description (short description of situation and choose one):

______

_____Lacks fixed, regular, and adequate nighttime residence.

_____ Awaiting foster care and placement.

_____ Shared housing (due to loss or hardship.)

_____ Inadequate shelter or housing.

_____Migratory who qualify as homeless because of living situation

_____ Non-traditional housing arrangement (hotel, motel, emergency or transitional shelter, trailer,

campground, etc.)

_____Live in cars, parks, public spaces, abandoned buildings, bus or train station, etc.)

_____Unaccompanied youth

_____Other______

_____Other______

Signature: ______

School Administrator (and/or)

Lisa West, Okaloosa County Homeless Liaison

Copies to:

Please send this form with the accompanying MIS 1502 Title X, Part C-Student Residency Information to the Okaloosa County Homeless Liaison.

Transportation Office Central, North, South:

School Guidance Counselor: ______

ADMINISTRATIVE COMPLEX- 120 LOWERY PLACE S.E.-FORT WALTON BEACH, FLORIDA 32548

TELEPHONE (850) 833-3100 FAX (850) 833-3436

CARVER HILL- 461 W. SCHOOL AVE.-CRESTVIEW, FLORIDA 32536

TELEPHONE (850) 689-7117 FAX (850) 689-7121