ࡱ> LPK9 bbjbj 86hh H H 8&<bLY'&&&&&&&$=*,~&&4'Fp%h&:8#,#IS(d# \%)'0Y'n#Rq-q-#q-#&&Y'q-H X : Your child may be eligible for additional educational services depending on your housing situation. Additional services and rights include the right to stay at the same school even if you move and access to free meals at school. Eligibility can be determined by completing this questionnaire. This information is only for education purposes and is protected as an educational record under the Federal Educational Rights and Privacy Act (FERPA). 1. Where have you and your family lived since July 1 of this year? Section A Live in my own home (rent or own) with immediate family (spouse/partner, children, parents). STOP: Please return this form without completing the remaining sections. Section B Where has your family stayed at night? Please check ALL the boxes for places you have slept over the past year. Staying temporarily with friends, relatives or other people (couch-surfing) With an adult that is not a parent or legal guardian At a hotel, motel, in a camper or 5th wheel In a place that lacks water, electricity, or heat; is infested with vermin or mold; lacks working kitchen or a working toilet; presents unreasonable dangers to adults, children, or persons with disabilities In a car, tent, park, bus or train station, abandoned building, shed, or other public place In a temporary shelter or other temporary housing In transitional housing or an independent living program Other (please note):_______________________________ CONTINUE: If you checked a box in Section B, complete the remainder of this form. 2. If you checked a box in Section B, your child(ren) may be eligible for additional support. Please list their information below, including children who are not yet school aged. Student(s) Name First Middle Last D.O.B. Grade School Name    Housing and Educational Rights Students without fixed, regular, and adequate nighttime residences have the following rights: Immediate enrollment in the school they last attended or the local school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations; Transportation to the school of origin for the regular school day; Access to free meals, Title I and other educational programs, and transportation to extra-curricular activities to the same extent that it is offered to other students. Any questions about these rights can be directed to the local McKinney-Vento liaison at or the State Coordinator at (207) 557-1787. By signing below, I acknowledge that I have received and understand the above rights. ______________________________________________________________________________ Signature of Parent/Guardian/Unaccompanied Youth Date ______________________________________________________________________________ Signature of McKinney-Vento Liaison Date     MCKINNEY-VENTO SCREENER School Name_________________________________ School District ________________________________________ /?lnvwyz $ ) 5 B K Y f       " $ % d j k l m q r ȽȭȏhCkh56CJ^JaJhCkh5>*CJ\^JaJhCkh55>*CJ^JaJh`3>*CJ^JaJhCkh5>*CJ^JaJhCkh5CJ^JaJh!6>*CJ^JaJhCkh56>*CJ^JaJ2   l m fekd$$Ifl4&4&04&64 lalytCk$h$If^ha$gdQU$ & F$Ifa$gd5 $$Ifa$gdQU$a$gd5 r   " $ % 2 3 X ^ _ d  " $ % 3 }}ppp}}}}}}}h*a|5>*CJ^JaJh*a|h55>*CJ^JaJh*a|h*a|5>*CJ^JaJh*a|>*CJ^JaJh*a|h*a|>*CJ^JaJh5>*CJ^JaJhCkh5>*CJ^JaJ hCkh5CJOJQJ^JaJhCkh55>*CJ^JaJhCkh56>*CJ^JaJ, 3  @ y  $$Ifa$gdQU$h$If^ha$gdQU$ & F$Ifa$gd*a| $$Ifa$gd*a| 3 > d i j    " $ % ? @ d i j x y ~  !#$)ŷuuuuuuuhCkh556CJ^JaJ#hCkh55CJOJQJ^JaJhCkh56>*CJ^JaJhCkh56>*CJ^JaJhCkh56CJ^JaJhCkh5>*CJ^JaJh*a|5>*CJ^JaJh*a|h*a|5>*CJ^JaJh*a|h55>*CJ^JaJ.# $IfgdQU $$Ifa$gdQUgd5ekd$$Ifl4&4&04&64 lalytCk )/5:Zc!#$%&'()*+,-./0123456789:;<D[\d߿ hCkhkCJOJQJ^JaJ hCkhsCJOJQJ^JaJ#hCkhCk5CJOJQJ^JaJhCkCJOJQJ^JaJ hCkhCkCJOJQJ^JaJhCkh556CJ^JaJ8#$%&'()^UUUUU $IfgdQUkd $$IfTl^\ ${:GWp 0H&4 laytCkT)*+,-./^UUUUU $IfgdQUkd$$IfTlh\ ${:GWp 0H&4 laytCkT/012345^UUUUU $IfgdQUkdn$$IfTl^\ ${:GWp 0H&4 laytCkT56789:;^UUUUU $IfgdQUkd$$IfTl^\ ${:GWp 0H&4 laytCkT;<[o^\ZUMUZZ & Fgd{ & Fkd$$IfTlh\ ${:GWp 0H&4 laytCkTd(,\^}~(,WZ\iC[\lmno޼޼޼޼޼޼ޮޝޮ hCkh5CJOJQJ^JaJh$CJOJQJ^JaJ hCkh{CJOJQJ^JaJ hCkh2CCJOJQJ^JaJ hCkhkCJOJQJ^JaJ hCkhlCJOJQJ^JaJ>PQ\]^_`ab*$dN^*`gd"gd$$a$gd$gd$gds)+,47AGJPQlϽrjffjffjffjffYYh$;CJOJQJ^JhlijhliU&hCkhk6CJOJQJ]^JaJ hCkhlCJOJQJ^JaJ&hCkhs6CJOJQJ]^JaJ#hCkhkCJOJQJ]^JaJ#hCkhsCJOJQJ]^JaJh!CJOJQJ]^JaJ hCkhCkCJOJQJ^JaJ hCkhkCJOJQJ^JaJ"!"#[\]^_`abѹ&hCkhk6CJOJQJ]^JaJhlihv"h"h5Y5CJOJQJ\aJhj h$h$ h$h$CJOJQJ^JaJ hCkh$CJOJQJ^JaJh$h$;CJOJQJ^Jh$;CJOJQJ^J6&P1h:pl/ =!"#$% $$Ifl!vh#v4&:V l04&654&4alytCk$$Ifl!vh#v4&:V l04&654&4alytCk$$If!vh#v:#vG#vW#vp :V l^0H&5:5G5W5p 4aytCkT$$If!vh#v:#vG#vW#vp :V lh0H&5:5G5W5p 4aytCkT$$If!vh#v:#vG#vW#vp :V l^0H&5:5G5W5p 4aytCkT$$If!vh#v:#vG#vW#vp :V l^0H&5:5G5W5p 4aytCkT$$If!vh#v:#vG#vW#vp :V lh0H&5:5G5W5p 4aytCkT"x02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH :@:  Heading 1$@&6]DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 2>@2 Title$a$5\4@4 Header  !4 @4 0Footer  !H"H  Balloon TextCJOJQJ^JaJ6/16 5Y0 Footer CharCJaJB' AB aOComment ReferenceCJaJ<R< aO Comment TextCJaJ:a: aOComment Text Char@jQR@ aOComment Subject5\F/F aOComment Subject Char5\>> S Footnote TextCJaJ<< SFootnote Text Char@& @ SFootnote ReferenceH*HJ@H 5Subtitle$a$5>*OJPJQJaJH/H 5 Subtitle Char5>*CJOJPJQJBB@B 5 Body Text6OJPJQJaJH/H 5Body Text Char6CJOJPJQJFPF !5 Body Text 2 CJOJPJQJaJD/D 5Body Text 2 Char OJPJQJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y b 86 r 3 )db  #)/5;b @ @ 0(  B S  ?H0(   ` c U^  ` c 33333z<<  C n n o o ^ _ ` c z<<  C n n o o ` c 4= 'UN=IA^`o()^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.hh^h`CJ$OJ QJ o(q ^`OJ QJ o(o pp^p`OJ QJ o( @ @ ^@ `OJQJo( ^`OJ QJ o(o ^`OJ QJ o( ^`OJQJo( ^`OJ QJ o(o PP^P`OJ QJ o(4= '=I         a`#$8{j - ,W;?s"C\KI y#'4(A(>*?.`3~3(68x8}:ѱ\$7\5V4<[`cyc`dli8jglmpnmoIq*a|z|!k]$%z4B50C?@ABDEFGHIJMNOnRSlUVWXYZ[\]^_`abcdefghijkmoRoot Entry F |ISQ@ Data 1Table$-WordDocument86SummaryInformation(;DocumentSummaryInformation8CMsoDataStore HSISEWTECKZJESSA==2HSиHSItem  PropertiesOGOR2RAUKSTNWBF==2 HSHSItem  PropertiesUKUKFERGQ==2HSISItem T.Properties}  !"#$%&(DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. tomXml">  F Microsoft Word 97-2003 DocumentCompObj'r MSWordDocWord.Document.89q