Student Homelessness Eligibility Questionnaire Form
Complete this Student Homelessness Eligibility Questionnaire Form to help determine whether you qualify for homelessness-related support. Please answer each question accurately based on your current situation.
Student Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Currently Enrolled
*
Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
*
Living with parent(s) or guardian(s)
Living with another family due to loss of housing or financial hardship
Staying in a shelter or transitional housing
Staying in a motel, hotel, or campground
Living in a car, park, abandoned building, or similar place
Other
How long have you been experiencing housing instability?
*
Please Select
Less than 1 month
1–3 months
4–6 months
7–12 months
More than 1 year
Are you currently living with your parent(s) or legal guardian(s)?
*
Yes
No
If not living with parent(s) or guardian(s), are you unaccompanied (not in the physical custody of a parent or guardian)?
*
Yes
No
Not applicable
Have you received homelessness-related support services from your school or community in the past 12 months?
*
Yes
No
Not sure
Submit Eligibility Questionnaire
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