STUDENT QUESTIONNAIRE | Academia Del Pueblo

Gender

Male

Female

Presently, where does the student stay at night?1. Is your current address a temporary living arrangement? Please check one:

Yes

No

Presently, where does the student stay at night? 2. Is this temporary living arrangement due to loss of housing or economic hardship? Please check one:

Yes

No

Where is the student presently living?

In a motel

In a shelter

With more than one family in a house or apartment

Moving from place to place

In a place not designed for ordinary sleeping accommodations (es. car, park and campsite)

I certify that the above- named student qualifies for the Child Nutrition Program under the provisions of the McKinney – Vento Act

Yes

No

Academy Del Pueblo Student Questionnaire

If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, please sign and date the bottom.

This questionnaire is intended to address the McKkinney – Vento Act 42 U.S.C 11435. The answers to this questionnaire information help determine the services the student may be eligible to receive.

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