PARISH PUBLIC SCHOOLS DATE ___________
[pic] TITLE X, PART C
MCKINNEY-VENTO CONFIDENTIAL REFERRAL FORM
Louisiana School District _________________________________________________________
Date______________ Not In School______
Student _________________________ (M/F) Parent/Guardian __________________Race ____
School _________________________Age____ Grade _____ Sp Ed Y/N D.O.B. ___________
S.S. # or I.D. # ___________________ Phone Number ____________________________
Temporary Address __________________________________ City __________ Zip __________
Referring Person ___________________________ Position _____________________________
Reason for referral: Problems listed below often prevent homeless children and youth from attending school. Please check the areas of concern, which apply to the student identified above.
Check all that apply:
___Student lacks a permanent residence
___Student is unable to pay school fees Doubled-Up/Unaccompanied Youth
___Immunizations are needed Hotel/Motel
___A birth certificate is needed Unsheltered
___Excessive absences are a problem Sheltered
___Lacks academic records and/or documentation
___Academic problems indicate a need for tutoring
___School supplies are needed
___Transportation to school is a problem
___Student/family needs assistance accessing community resources
___Behavior indicates a need for mental health counseling
___School clothes are needed:
Sizes: Shirt ____ Pants ____ Shoes ____ Other ____
___Free lunch form needed
___Health problems are indicated
___Guardianship is a problem
___IDEA services needed ___LEP/ESL services needed ___Migrant services needed
COMMENTS: ____________________________________________________________________
______________________________________________________________________________________________________________________________________________________________
(Other children in home: (Use back if necessary.)__________________________________________
______________________________________ ___________________________________
School Personnel Signature Homeless Liaison’s Signature
*LIAISON’S SIGNATURE INDICATES STUDENT(S) MEET TITLE X, PART C REQUIREMENTS
Copy sent to District Homeless Liaison Copy Placed in Student’s Cumulative Record
(Revised 3/2008)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- grade eight standards of learning for virginia public schools
- sample letter for public and private schools
- high school social studies lesson plans imperialism
- parish public schools date
- child psychology services
- tdap immunization requirements for entry into seventh grade
- language needs of school age children
- custer school district csd homepage
- petition for transfer of students
Related searches
- richmond public schools education found
- nyc public schools job openings
- baltimore city public schools schedule
- baltimore city public schools calendar
- maryland public schools report card
- oklahoma public schools report card
- baltimore city public schools jobs
- baltimore county public schools calendar
- baltimore city public schools self service
- baltimore county public schools calendar 2019 2020
- baltimore city public schools employee
- baltimore city public schools list