Exhibit JBC(1)-E(1): Homeless Students - 1

Date of homeless verification: _____________
                                                                                       Staff: __________________________________

                                                 Student Residency Questionnaire
Your child may be eligible for educational services through the Federal McKinney-Vento Act. Eligibility can be determined by completing
 this entire questionnaire. Please contact your School Social Worker for assistance if you have any questions regarding questionnaire.


        Residency Questions                 Does the student live in one of the                 Did student(s) living arrangements
 Further information may be required        following situations (nighttime dwelling)?          change due to any of the following?
    to determine eligibility status.                                                                 (Attach documents)

 Residing in own home                       Shelter: Emergency/ Domestic                       Eviction/ Foreclosure
 Living with someone by choice,                 Violence/ Transitional Program                     Date:______________________

    whereas housing is fixed, regular        Doubled-Up: shared housing due to                  Fire/ Natural Disaster/Uninhabitable
    and adequate.                                loss of housing and economic hardship              Date:______________________
                                             Unsheltered: Living in an abandoned                Loss of Employment
STOP: If you checked this section,               building, car, bus or train station                Date:______________________
you do not need to complete the
remainder of this form. Please submit
                                             Motel/ Hotel- due to loss of housing or            Domestic Violence/ Protective Order
                                                 eviction                                           Date:______________________
form to school registrar, social
worker, or school.                           Unaccompanied Homeless Youth                       Parent is Incarcerated, family was
                                                 Student is alone or with an adult that is          homeless prior to incarceration
How long have you been residing at               not a parent or legal guardian. Please             Date:_______________________
the current address?                             complete Caregiver Affidavit Form.
                                                                                                 Abandoned or asked to leave
________________________________             Migratory Youth living in one of the                  residence by parent or legal guardian
                                                 above situations                                   Date:_______________________
________________________________
                                                                                                 Voluntarily left residence or home
                                                                                                    Date: ______________________
    Failure to provide complete and accurate information may result in an ineligibility status for McKinney Vento Program Services.

Parent/Guardian Name: ______________________________________________                      Phone Number: _________________________

Current Address & Rm #: _____________________________________________________________________________________

Name of Shelter/Apartments/Hotel: _____________________________________________Main Phone:_____________________


Student’s Name & ID                                   D.O.B.        Grade        Previous Enrolled            Requesting School of
                                                                                      School                      Enrollment




Please check Homeless Education Services requested for enrollment below:

     School Nutrition/ Free Meals                  Transportation (outside of                     Immunizations (school
                                                        school zone/ district)                          enrollment only)

     Dental screening (school                      Vision screening (school                       Hearing Screening (school
         enrollment only)                               enrollment only)                                enrollment only)

     School Supplies                               School Uniform                                 None at this time
School personnel: Submit a referral to your assigned school based social worker for community resources. For additional resources and
services email or fax a copy of this form to Homeless Ed Liaisons at 678-676-1831.
JBC (1) –E (1), Revised January 2018

Legal References

• O.C.G.A. 20-02-0150 — Eligibility for enrollment (Lexis)
• O.C.G.A. 20-02-0293 — Student attending school in system other than system of student's residence (Lexis)
• O.C.G.A. 20-02-0690.1 — Mandatory education for children between ages six and 16 (Lexis)
• O.C.G.A. 20-02-0694 — Administration and enforcement of attendance requirements (Lexis)
• O.C.G.A. 20-02-1076 — Alternative vehicles for school buses; limitations on use; requirements; insurance (Lexis)
• O.C.G.A. 20-03-0066 — Determination of in-state resident status of students for tuition or fees (Lexis)
• Rule 160-5-1-.28 — Student Enrollment and Withdrawal
• Rule 160-5-3-.17 — Use of Alternative Vehicles for the Transport of Students
• 42 USC 11431 — Education for Homeless Children and Youths