Utah Virtual Academy

Enrollment Processing Center

2300 Corporate Park Drive
Suite 200
Herndon, VA 20171
Ph. 877-257-4608
Fx. 877-257-4613
www.k12.com/utva

McKinney-Vento Eligibility Questionnaire

This questionnaire is intended to address the McKinney-Vento Act. Your answers will help administrators determine residency documents necessary
for enrollment of this student and to determine services the student may be eligible to receive. Please answer the 3 questions below to help us
determine McKinney-Vento eligibility.
1. Presently, where is the student living (circle one)?

A.

in a shelter

B.

with more than one family in a house or apartment

C.

in a motel, car or campsite

D.

with friends or family members (other than parent/guardian)

E.

in foster care

F.

with parent or legal guardian

2. How long has your student lived in your current residence?

3. Have you been forced in/from your current residence because of economic hardship or other hardship? o Yes o No
If yes, please explain:




4. Do you work in agriculture and does your residence depend on seasonal work? o Yes o No

Name of Student: Birthdate:

Name of Parent(s)/Legal Guardian(s):

Signature of Parent/Legal Guardian: Date: