Human Services Online Submission Forms

LYON COUNTY HUMAN SERVICES
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Lyon County Schools: McKinney-Vento Intake Affidavit

  1. Lyon County Schools

  2. McKinney-Vento Intake Affidavit

  3. Siblings of Student:

  4. Is there a copy of your student's Birth Certificate on file at the school?

  5. If you answered NO, do you need assistance with obtaining a copy?

  6. 1. Where is the student currently living? (Check box)

  7. 4. With whom does the student currently live: (check box)

  8. 7. In your child's previous school, did he/she receive any of the following?

    (Check all that apply)

  9. 8. At this time, what is the greatest need for your child?

    (Check all that apply)

    (1) the information I have provided on this form is true and accurate to the best of my knowledge or belief; (2) the same information, as well as other information that may identify my child(ren), may be shared without my consent with community and governmental agencies pursuant to an interagency collaboration between this school district, Lyon County Human Services, and Healthy Communities Coalition; (3) the same information, as well as other information that may identify my child(ren), may be shared without my consent with other LCSD staff members for a legitimate educational purpose. In addition, my signature affirms that I have received a copy of my rights under the McKinney-Vento law and I agree to allow LCSD staff to conduct screenings as a part of the district's McKinney-Vento program.

  10. (Or Unaccompanied Youth)

  11. Revised 06/08/2017

  12. Leave This Blank:

  13. This field is not part of the form submission.