Forms Portal
Date of Birth
Current Signature


Name of Student: 

Birth Date:



This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C 11435. The answers to this residency information help determine the services the student may be able to receive.

1.  Is your current address a temporary living arrangement? *

2.  Is this temporary living arrangement due to the loss of housing or economic hardship?

You answered YES to one of the questions above. Please fill out the remainder of the form.

Where is the student presently living?



Print Name of Parent or Legal Guardian

Street Address


City, State, Zip

Note: Presenting a false record or falsifying records is an offense under Section 37.10, Penal Code, and enrollment of the child under false documents subjects the person to liability for tuition and other costs.

Current Signature

Signature of Parent or Legal Guardian (use mouse to sign) 

Complete Legal Name of Student

Has your Child ever attended Jordan-Elbridge Schools in the past?

Parent / Legal Guardian information (residing with student)

Parent / Legal Guardian information (residing with student)

Can they be called for emergencies by the district?

Is your child Hispanic, Latino, or of Spanish Origin?



If YES, please check services received below:

Physical Address:*

Mailing Address:*

Cell Phone:

Parent's Name:

Email Address:

Foster Care Placement Must  Provide

Form DSS-2999

Placement is considered to last for what period of time?

School Phone:






Before submitting this form, please check your answers. Any questions with a red * are required. After submitting the form if you get a validation error, please look for and complete any questions/fields that turn red. 


Is this the primary contact number?

If parents do not reside in same household, please identify arrangement.          I have:

Court papers must be on file with the Jordan-Elbridge Central School District giving specific instructions regarding custody of student and access to records Complete information on both parents is required if joint custody exists:

Is the Student considered Neglected/Delinquent?

(Hispanic, Latino or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race)

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In order to provide your child with the best possible education, we need to determine how well he or she understands, speaks, reads and writes in English

In what language(s) would you like to receive information from the school?

What is the Home Language of each parent/guardian?

What was the first language your child learned?

What language(s) does your child understand?

What language(s) does your child speak?

What language(s) does your child read?

What language(s) does your child write?

Language Background (Please check all that apply.)

Educational History

Do you think your child may have any difficulties or conditions that affect his or her ability to understand, speak, read or write in English or any other language?

You indicated your child has been referred in the past, has your child ever received any special education services in the past?

Age at which services received (Please check all that apply):

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Is there anything else you think is important for the school to know about your child? (e.g., special talents, health concerns, etc.)


For students with disabilities, list accomodations administered in accordance with IEP pursuant to CSE recommendation:

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