BIE-MCKINNEY-VENTO STUDENT RESIDENCY VERIFICATION DOCUMENT BIE-MCKINNEY-VENTO This document is intended to address the McKinney-Vento Act. Your answers will help the administrator determine the residency documents necessary for enrollment of this student. 1. Presently, where is the student living? (Check One Box) SECTION A in a shelter with more than one family in a House or Apartment in a motel, car or campsite with friends or family members (other than parent/guardian) SECTION B Choices in Section A do not apply CONTINUE: If you checked a box in SECTION A, complete #2 and the remainder of this form. STOP If you checked this section, you do NOT need to complete the remainder of this form. Submit to school personnel. 2. The student lives with 1 Parent 2 Parents 1 Parent & Another Adult A relative, friend(s) or other adult(s) Alone with no Adults An Adult that is not the parent or the legal guardian School * Name of Student * Name of Student First Name First Name Last Name Last Name Gender * Male Female Birth Date * Age * Social Security# (if appropriate) Name of Parent(s)/Legal Guardian(s) * Name of Parent(s)/Legal Guardian(s) First Name First Name Last Name Last Name Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Address Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
