Exhibit JBC(1)-E(2): Homeless Students - 2

DEKALB COUNTY SCHOOL DISTRICT
                       EDUCATION OF HOMELESS CHILDREN AND YOUTH

                                 UNACCOMPANIED HOMELESS YOUTH
                                 CAREGIVER’S AUTHORIZATION FORM

This form is intended to address the McKinney-Vento Homeless Education Assistance Act requirement
that homeless children are to have comparable education services. In some cases, a youth who is
homeless may not be able to reside with his/her parent or legal guardian, and may reside with a caring
adult.

Instructions: Complete and sign this form as the acting adult caregiver in lieu of parent/ legal
guardian.

The minor named below lives in my home, and I am 18 years of age or older.

1.    Name of student: ___________________________________________________________________
2.    Student’s Date of Birth:______________________________________________________________
3.    Name of Authorized Adult Caregiver: __________________________________________________
4.    Caregiver’s Date of Birth: ____________________________________________________________
5.    List all phone numbers (cell, home, work): _______________________________________________
6.    My home address:___________________________________________________________________

7. Check one or both (for example, if one parent was advised and the other could not be located):

       I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to
      authorize medical care and have received no objection.

       I am unable to contact the parent(s) or legal guardian(s) at this time to notify them of my intended
      authorization.

8. Emergency Contact: __________________________________________________________________

     ______________________________________                                  ___________________________________
     Authorized Caregiver                                                    Date

     ______________________________________                                   __________________________________
     School Personnel (Principal or Designee)                                 Date


The DeKalb County School District does not discriminate on the basis of race, color, religion, sex, age, national origin,
disability, veteran status, marital status, or sexual orientation in any of its employment practices, educational programs, services
or activities. For additional information about nondiscrimination provisions, please contact Student Support & Interventions
located at 1701 Mountain Industrial Boulevard, Stone Mountain, GA 30083. Phone number 678-676-1200.



                                                                                         JBC (1) –E (2), 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