ORANGE COUNTY PUBLIC SCHOOLS TAYLOR EDUCATION ADMINISTRATION COMPLEX 200 DAILEY DRIVE ORANGE, VIRGINIA 22960 www.ocss-va.org 540-661-4550 Fax 540-661-4599

Orange County Public Schools McKinney-Vento Act/ Project Hope Referral Form

Student Name:

School:

Date of Student Enrollment:

D.O.B.: __________________ Grade:

Age:

Parent’s Name: Phone number: Other Contact Information: Please indicate the initial primary nighttime residence code as shown below. Housing Explanation Options

1-Unshelterd

2-Shelters 3-Doubled -up 4-Hotel/Motel

Check Accurate summary of conditions

Children and youth living in abandoned buildings, campgrounds and vehicles, space not meant or habitation. An inadequate dwelling may shelter but it is not adequate housing Children and youth living in shelters and transitional housing programs and/or awaiting foster care placement Children and youth (including runaway youth or unaccompanied youth)who live with relatives or friends due to being homeless Children and youth living in hotels/motels due to a lack of alternative adequate accommodations

I have received information about Project Hope resources.

____________________________________________

__________________

Parent/Guardian Signature

date

_____________________________________________ Attendance Clerk

____________________ date

The School Attendance Clerk should complete this referral form the first day of student enrollment and forwarded to the Office of Student Services. The student’s eligibility determination for this program is determined yearly.

____ This student is eligible for the PROJECT HOPE program. _______________________________________________________ Homeless Education Liaison

________________________ date

The Orange County School Board does not discriminate on the basis of race, color, religion, national origin, ancestry, political affiliation, sex, gender, age, marital status, genetic information or disability in its employment practices or educational program and activities. Compliance inquiries should be directed to the Director of Human Resources, 200 Dailey Drive, Orange, VA 22960 or by phone at 540-661-4550.