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INDIANA DEPARTMENT OF EDUCATION
Indiana Education for Homeless Children & Youth (INEHCY) McKinney-Vento Homeless Education Program
Language
Name of LEA
Name of School
Please Select
Andrews
Crestview Middle School
Flint Springs
Horace Mann
Huntington North High School
Lincoln
Riverview Middle School
Roanoke
Salamonie
Name of School (text)
Principal Email
example@example.com
Assistant Principal Email
example@example.com
Secretary Email
example@example.com
Secretary 2 Email
example@example.com
Guidance Counselor Email
example@example.com
Name of Student
First Name
Middle Name
Last Name
Does your student have an IEP (Individualized Education Program)?
Yes
No
Special Services -Director Email
example@example.com
Special Services Email
example@example.com
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
Grade
Please Select
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
13
ID#
Address (if available- primary location student stays):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Does the student need transportation to school?
*
Yes
No
The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don't have the documents normally needed, such as proof of residency, school records, immunizations records, birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living? (Please mark all that apply)
In a shelter
With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as "doubled-up")
In a hotel/motel
In a car, park, bus, train, or campsite
Other temporary living situation
In permanent housing
Unaccompanied Youth
If you marked Other temporary living situation please describe here:
Parent /Guardian Name
Signature of Parent /Guardian
Parent Email
example@example.com
Student Name (for unaccompanied homeless youth only)
Student Signature (for unaccompanied homeless youth only)
Student Email
example@example.com
Additional Information in place of parent signature
Date
/
Month
/
Day
Year
Date
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