STUDENTS IN TRANSITION (SIT) PROGRAM MCKINNEY-VENTO ACT

STUDENTS IN TRANSITION (SIT) PROGRAM MCKINNEY-VENTO ACT

MIS 140
Rev. 04/24

The Pasco County School District wants to make sure that your child receives the best possible education. The information from this form will help to determine if your student is able to receive benefits under the federal McKinney-Vento Act, a law that helps students who are temporarily displaced from their home for certain reasons.

A student qualifies for the McKinney-Vento Act if they are enrolled in a Pasco County Public School (pre-k through 12th grade) and lack a fixed, regular and adequate nighttime residence. Specifically, if a student lives under any of these conditions:
• sharing housing of other persons temporarily due to loss of housing, economic hardship, or a similar reason
• living in an emergency or traditional shelter (family, youth or domestic violence shelter or transitional living program)
• living in motels, hotels, temporary trailer parks, or campgrounds due to the lack of alternative adequate accommodations
• living in cars, parks, public spaces, abandoned buildings, substandard housing(without electricity or running water), bus or train stations, or similar settings
• Migratory children living in one of the above circumstances
• Unaccompanied youth(student not accompanied by a legal guardian) and living in one of the above circumstances

PLEASE DO NOT complete this form if your housing DOES NOT meet one of the conditions listed above. If you rent, share housing for convenience, or if you are buying a house and do not need support services, your students DO NOT qualify for the McKinney-Vento Act.

STUDENT INFORMATION:

School-Aged AND Non School-Aged Children - List ALL children in your family
How many children are in the household?
Student #1:
Student 1 (OTHER) Name of school, County and State
Student 1 Name: Student 1 Name: First Last
Student 1 ID:
Student 1 DOB: Student 1 DOB: / MM / DD YYYY
Student 1 Sex:

Student 1 Sex: Male Female
Student 1 Grade
Student 1 School
Student #2
Student 2 Name Student 2 Name First Last
Student 2 ID
Student 2 DOB Student 2 DOB / MM / DD YYYY
Student 2 Sex

Student 2 Sex Male Female
Student 2 School
Student 2 Grade
Student 2 (OTHER) Name of school, County and State
Student #3:
Student 3 Name: Student 3 Name: First Last
Student 3 DOB: Student 3 DOB: / MM / DD YYYY
Student 3 Sex:

Student 3 Sex: Male Female
Student 3 ID:
Student 3 School:
Student 3 Grade:
Student 3 (OTHER) Name of school, County and State
Student #4:
Student 4 Name: Student 4 Name: First Last
Student 4 DOB: Student 4 DOB: / MM / DD YYYY
Student 4 Sex:

Student 4 Sex: Male Female
Student 4 ID:
Student 4 School:
Student 4 Grade:
Student 4 (OTHER) Name of school, County and State
Student #5:
Student 5 Name: Student 5 Name: First Last
Student 5 DOB: Student 5 DOB: / MM / DD YYYY
Student 5 Sex:

Student 5 Sex: Male Female
Student 5 ID:
Student 5 School:
Student 5 Grade:
Student 5 (OTHER) Name of school, County and State
Student #6:
Student 6 Name: Student 6 Name: First Last
Student 6 DOB: Student 6 DOB: / MM / DD YYYY
Student 6 Sex:

Student 6 Sex: Male Female
Student 6 ID:
Student 6 School:
Student 6 Grade:
Student 6 (OTHER) Name of school, County and State
Student #7:
Student 7 Name: Student 7 Name: First Last
Student 7 DOB: Student 7 DOB: / MM / DD YYYY
Student 7 Sex:

Student 7 Sex: Male Female
Student 7 ID:
Student 7 School:
Student 7 Grade:
Student 7 (OTHER) Name of school, County and State
HOUSING INFORMATION:
Where is/are the student(s) living at this time?:

Where is/are the student(s) living at this time?: An emergency or transitional shelter (A) Temporarily with another family due to loss of housing, economic hardship or similar reason (B) A vehicle of any kind, trailer park or campground, abandoned building or other substandard housing (D) A hotel/motel due to loss of housing, economic hardship or similar reason (E)
Reason for temporary living: (If due to COVID-19, please select all that apply):

Reason for temporary living: (If due to COVID-19, please select all that apply): Foreclosure (M) Tornado (T) Flooding (F) Eviction House Fire Earthquake (E) Unemployment Wildfire (W) Tropical Storm (S) COVID-19 (P) Man Made Disaster (D) Hurricane (H) Other Other
Tropical Storm Name:
Hurricane Name:
The student(s) is/are:

The student(s) is/are: in the physical custody of a parent or legal guardian NOT in the physical custody of a parent or legal guardian (ex: living alone, with a relative who is not their legal guardian, living with other people, etc.) .
Student Contact Information for Unaccompanied Youth:
Email
Phone Phone - ### - ### ####
PARENT/LEGAL GUARDIAN/CAREGIVER CONTACT INFORMATION
Parent/Legal Guardian/Caregiver Name: Parent/Legal Guardian/Caregiver Name: First Last
Relationship to student:
Temporary address or location of housing: Temporary address or location of housing:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Former Address: Former Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Previous address student lived in.
Cell Phone: Cell Phone: - ### - ### ####
Alt Phone: Alt Phone: - ### - ### ####
Email:
Primary Language Spoken:
How long has/have the student(s) been in the TEMPORARY place?:
Student is in School Zone:

Student is in School Zone: YES NO

If student is living in school zone a bus can be requested through your school.
SIT Bus Required:

SIT Bus Required: YES NO
SIGNATURES
The undersigned certifies that the information provided is accurate and true.

Florida Statute 837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty shall be guilty of a misdemeanor of the second degree.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Name of the Person Completing This Form: Name of the Person Completing This Form: First Last
Relationship to the student:

Relationship to the student: Parent Guardian Caregiver Unaccompanied Youth Designee
Today's Date Today's Date / MM / DD YYYY

Date the form is submitted
Email of the Person Completing This Form

Use if you would like a copy of the completed form for your records