Verification of Residence

Verification of Residence
School Name*
Household Email*

Confirmation Emailexample@example.com
Please select whether or not at least one parent/guardian is an active member of the United States Armed Forces*

Yes, at least one parent/guardian is an active member of the United States Armed Forces.No, this student does not have a parent/guardian who is active in the United States Armed Forces.
Please describe your current living arrangement*

I have a stable place to stay at night. I currently live with someone as a result of difficult circumstances, and unfortunately, I am unable to provide official documentation of my residence.I have a stable place to stay at night. I currently live with someone by personal choice and I am unable to provide any legal documentation to verify my residenceI currently do not have a permanent nighttime residence and am unable to provide legal documentation of my residence.
The following form will need to be completed by a parent/guardian and the homeowner/lessee who can verify the information provided.
Affidavit to Verify Residence Form

This form is to be used either when the parent/legal guardian is permanently residing with someone and cannot provide legal proof of residency for themselves.
Parent or Guardian*

First NameLast Name
I declare I am the parent/legal guardian of*
Primary Phone Number*
Current physical address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To be completed by Property Owner or Renter:
Name of Property Owner or Renter*

First NameLast Name
Property Owner or Renter's Phone Number*
Please enter a valid phone number.
By signing below, I, the Property Owner or Renter, declare under penalty of perjury under the laws of California that the above statements are, to the best of my knowledge, true and correct.
Property Owner or Renter Signature*
Housing Questionnaire

This form is to be used either when the parent/legal guardian is currently lacking permanent nighttime residence and cannot provide legal proof of residency for themselves. If at any point you have any questions regarding the Housing Questionnaire, you may contact our Homeless Liaison, Dr. Yolanda Vazquez. | yolanda.vazquez@centralvcs.org | (559)258-1931
To be completed by Parent/Guardian:

Students residing with a Relative, Guardian, or Caretaker must have a Caregiver's Authorization Affidavit on file. The information provided below will help the LEA determine what services you and/or your child may be eligible toreceive. This could include additional educational services through Title I, Part A and/or the federal McKinney-VentoAssistance Act. The information provided on this form will be kept confidential and only shared with appropriateschool district and site staff.
Student(s) receive services in (check all that apply):*

ELD (English Language Development)Special EducationMigrant EducationNone of the above
Student(s) live with:*

ParentRelative, Guardian, or CaretakerFoster ParentUnaccompanied Youth (alone with no adults)
Contact Information

This information will be used for contact regarding emergencies and to send school reports
Parent/Guardian Name*

First NameLast Name
I declare I am the parent/legal guardian of*
Day Phone Number*
Evening Phone Number
Parent/Guardian Email Address*
example@example.com
Please select any any of the following living situations:*

Staying in a shelter (family shelter, domestic violence shelter, youth shelter) or Federal Emergency Management Agency (FEMA) trailer.Sharing housing with other(s) due to loss of housing, economic hardship, natural disaster, lack of adequate housing, or similar reason.Living in a car, park, campground, abandoned building, or other inadequate accommodations (i.e. lack of water, electricity, or heat).Temporarily living in a motel or hotel due to loss of housing, economic hardship,natural disaster, or similar reason
I am the student under the age of 18 living apart from parent(s) or guardian.*

YesNo
Physical Address.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your child or children may have the right to:
• Immediate enrollment in the school they last attended (school of origin) or the local school where you are
currently staying, even if you do not have all the documents normally required at the time of enrollment.
• Continue to attend their school of origin, if requested by you and it is in the best interest.
• Receive the full protections and services provided under all federal and state laws, as it relates to homeless
children, youth, and their families.
Date since family has not had permanent residence*

MonthDayYear
Date
I declare that I am the parent/legal guardian/caregiver of my student. We are currently residing at the address listed above. I declare under penalty of perjury under the laws of California that the above statements are, to the best of my knowledge, true and correct. Please sign below.*

Clear
Should be Empty:

Verification of Residence

Affidavit to Verify Residence Form

To be completed by Property Owner or Renter:

Housing Questionnaire

To be completed by Parent/Guardian: