White Settlement

Independent

School District

Residency Questionnaire

1. Name of student ______Male Female

Birth Date ___/___/______Age______

2. Presently, where is the student living? Check one box:

____Section A / ____Section B
In a Shelter
With more than one family in a house or
apartment (another family rents or owns
house or apartment
In a motel, car or campsite
Continue: If you checked Section A, complete #3 and the remainder of this form. / Choices in Section A do not apply
Stop: If you checked this section, you do not need to complete the remainder of this form.
Submit to school personnel.

3. The student lives with :

___1 parent ___a relative, friend(s) or other adult(s)

___2 parents ___alone with no adult

___1 parent and another adult ___an adult that is not the legal parent or guardian

School ______Social Security #______/______/______

Name of Parent(s)/Legal Guardian(s)______

Address______Zip______Phone______

Signature of Parent/Legal Guardian______Date______

Presenting a false record or falsifying records is an offense under Section 37.10, Penal Code and enrollment of the child under false documents subjects the person to liability for tuition and other costs. TEC Sec. 25.002(3)(d).

______

School use only – Campus Administrator’s determination of Section A circumstance:
Student lives apart from parent/guardian fro school purposes.
Student and parent live with another family – not homeless.
Student comes under the McKinney Act.
Instructions fro Registrars:
1.  Send questionnaire to campus administrator.
2.  Keep a file of all questionnaires of homeless students.
3.  Discard questionnaires fro non-homeless students.
4.  Contact District Homeless Liaison.

401 South Cherry Lane

White Settlement, Texas 76108-2518

(817) 367-1350 FAX (817) 367-1391

Website: http://www.wsisd.net

Learning: A Life-Long Commitment