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TITLE X, PART C MCKINNEY-VENTO CONFIDENTIAL REFERRAL FORM

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TITLE X, PART C
MCKINNEY-VENTO CONFIDENTIAL REFERRAL FORM
Louisiana School District ___________________________________________________________________________________________
Date ____________________ Not In School ___________________
Student _______________________________ (M/F) Parent/Guardian _______________________ Race _____________
School _________________________________ Age ______________ Grade ______________ Special Ed: Yes _______ No ______
S.S.# or I.D.# __________________ D.O.B. ___________ Phone Number ________________
Temporary Address __________________________________ City __________ Zip _________
Referring Person ________________________________________ Position ________________________________________________
Reason for referral: Problems listed below often prevent homeless children and youth from attending school. Please check the areas of
concern which apply to the student identied above.
___ Student lacks a permanent residence
___ Student is unable to pay school fees
___ Immunizations are needed
___ Birth certicate is needed
___ Excessive absences are a problem
___ Lacks academic records and/or documentation
___ Academic problems indicate a need for tutoring
___ School supplies are needed
___ Transportation to school is a problem
___ Student/family needs assistance accessing community resources
___ Behavior indicates a need for mental health counseling
___ School clothes are needed (Sizes: Shirt _____ Pants ______ Shoes _____ Other _____ )
___ Free lunch form needed
___ Health problems are indicated
___ Need Health Insurance (LA CHIP/Medical Card)
___ Guardianship is a problem
___ IDEA (gifted, talented, disabilities) services needed
___ LEP/ESL services needed
___ Migrant services needed
COMMENTS: ______________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Other children in home:______________________________________________________________________________________________
_______________________________________________________ ______________________________________________________
School Personnel Signature Date Homeless Liaison’s Signature Date
*LIAISON’S SIGNATURE INDICATES STUDENT(S) MEET TITLE X, PART C REQUIREMENTS
 Copy sent to District Homeless Liaison Copy Placed in Student’s Cumulative Record
(Revised 4/2011)
Check all that apply:
Sheltered (1)
Doubled-Up (2)
Unsheltered/FEMA (3)
Hotel/Motel (4)
Unaccompanied Youth: Yes No
01 – Mortgage Foreclosure
02 - Flooding
03 - Hurricane
04 - Tropical Storm
05 - Tornado
06 - Wildre or Fire
07 – Man-made Disaster (Major)
99 – Other: i.e., lack of aordable
housing,long-term poverty, Unemployment
or underemployment, lack of aordable,
health care, mental illness, domestic
violence, forced eviction, etc.
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TITLE X, PART C MCKINNEY-VENTO CONFIDENTIAL REFERRAL FORM

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Completed 5 August 2021

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