Lyon County Schools: McKinney-Vento Intake Affidavit

2. Lyon County Schools

3. McKinney-Vento Intake Affidavit

5. Student's Name:*

6. ID#

8. Age:

9. Grade:

10. Gender:
    -- Select One --FemaleMale

12. Parent/Guardian Name(s):

13. Home Phone:

14. Mobile Phone:

16. Address:

17. City:

18. Zip code:

20. Home School (based on current residence):

21. School of Origin (last school attended):

23. Siblings of Student:

26. Name

27. School

28. Age

30. Name

31. School

32. Age

34. Name

35. School

36. Age

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

    1. Yes

    1. No

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

    1. Yes

    1. No

41. If you answered YES, please list your child's birth city and state below:

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

    1. In a motel/hotel- Name of motel/hotel:
    2. In a shelter- Name of Shelter:
    3. Transitional Housing- Name of transitional housing:
    4. Group Home- Name of group home:
    5. Temporary/emergency foster home
    6. With more than one family in a house of apartment
    7. Moving from place to place
    8. In a location not designed for sleeping accommodations such as a car, park, or campsite

46. Living status comments:

48. 2. How long have you lived at this residence?

49. 3. How long do you plan to live at this residence?

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

    1. Both parents
    2. One parent (which parent?)
    3. One parent (which parent?) and another adult
    4. A relative (Specify which, e.g. grandmother)
    5. Friends or other adults (please identify)
    6. An adult who is not a parent or legal guardian (please identify)

52. Explain (checked box):

54. 5. Describe the current living situation in detail:

56. 6. Any possibility of violence or abuse in home? If so, describe. What were the school's actions?

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

    (Check all that apply)

    1. Special Education/Exceptional Children's Services- Describe:
    2. 504 Accommodation Plan- Describe:
    3. English As a Secondary Language (ESL) services
    4. Help for Behavior Improvement
    5. Tutoring Services
    6. Academically or Intellectually Gifted services
    7. Counseling services
59. Describe:

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

    (Check all that apply)

    1. School supplies
    2. Clothing for school
    3. Free & Reduced Meal Program
    4. Help for academic improvement
    5. Help for behavior improvement
    6. Referral for for food assistance
    7. Medical referral/immunizations
    8. Mental health/counseling referral
    9. Transportation
    10. Weekend Backpack Program (if applicable)
    11. Other- Please describe:
62. Describe:

66. 1. My signature below affirms the following:

    (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.

68. Parent/Guardian Signature:*

    (Or Unaccompanied Youth)

69. Date:*
    Date:

    Date:

71. MCV Liaison Signature:*

72. Date*
    Date

    Date

74. Optional File Upload:

76. Revised 06/08/2017

Leave This Blank:


78. 1. Receive email copy
79. Email address

    This field is not part of the form submission.

80. Submit Submit and Print

* indicates a required field