STUDENT RESIDENCY QUESTIONNAIRE/AFFIDAVIT
This document is intended to address the McKinney-Vento Assistance Act. Your answers will help determine
documents necessary to enroll your child quickly.
Student: ____________________________________________ (Male ___ Female___)
Birthdate: ___________________________

Grade: ____________

1. Do you and your student live in a fixed, regular, adequate nighttime residence? Yes___ No___
(If you circled “Yes”, stop here. You must provide a gas or electric bill in your name as proof
of residence. If you circled “NO”, please continue with this form.)
2. Do you and the student live in:
□ shelter
□ motel/hotel
□ temporarily with another family in a house, mobile home, or apartment
□ in a car or RV
□ at a campsite
□ transitional housing
□ other location ________________________________________________________
3. The student lives with:
□ one parent
□ two parents
□ a qualified relative
□ friend(s)
□ an adult that is not the legal guardian
□ alone with no adult(s)
4. I am:
□ the parent/legal guardian of the above-named student
□ a qualified adult relative of the above-named student
(Relationship: _______________________________________________________)
I declare under penalty of perjury under the laws of this state that the information provided here is
true and correct and of my own personal knowledge.
Signature: _________________________________________

Date: __________________

Print Your Name: _______________________________________________________________
Residence: ____________________________________________________________________
Street
City
Zip
Mailing Address:
_____________________________________________________________________________
Street
City
Zip
Telephone: (_____) _____________________ Cell Phone: (_____) _______________________
California Department of Education
1/9/2012