Portal

Change of Address Form

Parent/Legal Guardian signature (use mouse to sign)

Name of Parent/Legal Guardian

STUDENT INFORMATION

Middle Initial

ACKNOWLEDGEMENT

Date*

Relationship to Student

Please verify your answers. After pressing SUBMIT FORM, if there are errors, they will be noted in red.

Last Name*

First Name*

Date of Birth*

Start Date of New Address*

NEW Residence Address (Street, Bldg/Apt#, City, State, Zip Code)*

The answer you give below will help the district determine what services you or your child(ren) may be able to receive under the McKinney-Vento Act. Your answer will be kept confidential and will only be shared with those staff responsible for providing services to the student and keeping track of how many students are identified as living in temporary housing. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

In a shelter

With another family or other person because of loss of housing or as a result of economic hardship

In a hotel/motel

In a car, park, bus, train, or campsite

Other temporary living situation (please describe):

In permanent housing

Where is the student currently living? (Please select one )

(sometimes referred to as "doubled up")

Any change to a student’s home address requires that new proof of residency be provided to the district registrar. Acceptable documentation includes, but is not limited to: closing document, deed, mortgage statement, signed residential lease, rental agreement, current utility bill, recent property tax or school tax bill, DSS or SSI paperwork with your name and new address. This can be done in person or by using the "Document Attachment Form" on the District website registration page.

ITHACA CITY SCHOOL DISTRICT

400 Lake Street • P.O. Box 549 • Ithaca, New York • 14851-0549

CURRENT Residence Address (Street, Bldg/Apt#, City, State, Zip Code)*

CURRENT Mailing Address (if different from Residence Address)

ADDRESS and CONTACT INFORMATION

NEW Mailing Address (if different from Residence Address)

Other Changes to Contact Information (if applicable)

Home Phone:

Cell Phone:

Work Phone:

Email Address:

A Last Name	B First Name	C Grade	D School	E Student ID

Office Use

Please list all students who reside at the new address (oldest first)

OFFICE USE ONLY

Student ID: