MANCHESTER SCHOOL DISTRICT SCHOOL ADMINISTRATIVE UNIT NO. 37 195 McGregor Street, Suite 201 Manchester, NH 03102 Telephone: 603.624.6300 • Fax: 603.624.6337

McKinney-Vento Residency Form: The questions below are to assist in determining if students meet the eligibility criteria for services provided under the McKinney-Vento Act. The McKinney-Vento Homeless Education Assistance Act is a federal law that ensures immediate enrollment and educational stability for displaced children and youth. The information you provide will be kept confidential. If you have any questions or concerns, please call the Manchester School District Homeless Education Liaison, Jocelyne Pinsonneault at 665-6868. Is your current address temporary in one of the following situations: (Check one) □ In a motel / hotel □ In a shelter i.e. Families in Transition, Emergency Shelter, Rooming House □ With more than one family in a house or an apartment □ Moving from place to place □ In a place not designed for ordinary sleeping accommodations, such as a car, park, campsite

**PLEASE COMPLETE INFORMATION BELOW ONLY IF YOU ANSWERED YES TO ABOVE QUESTION** Name of all your students in Manchester School District: (You only need to fill out one form per family) First Name

Last Name

Grade

School

***Do you have a preschooler at home? Yes / No *** Please check the following: Are you the: Student’s Parent:

Student’s Guardian:

or an Unaccompanied Youth*:

*(A youth is considered unaccompanied if he or she is under 18 years of age and is not living with a parent or a legal guardian)

Address where student(s) is/are staying: __________________________________________________________ Date: _______________________ Phone Number: _____________________ Cell or House phone (circle one) Under penalty of perjury under the laws of this state, I declare that the information provided here is true and correct and of my own personal knowledge, and if called upon to testify, I would be capable to do so. Name of person completing this form: ____________________________________________________________ (Please Print Name)

Signature of person completing this form: _________________________________________________________

It is the policy of the Manchester Board of School Committee, in its actions, and those of its employees, that there shall be no discrimination on the basis of age, sex, race, color, marital status, physical or mental disability, religious creed, national origin or sexual orientation for employment in, or operation and administration of any program or activity in the Manchester School District. The Title IX Coordinator is Pamela Hogan; the 504 Coordinator is Sharon DeVincent. Please see above for contact information.