McKinney-Vento Verification Form - Asheville City Schools

Rev. 10/2010
MCKINNEY-VENTO VERIFICATION
_________ - ________ SCHOOL YEAR
Student’s Last Name _____________________First Name ______________________ NCWise # ______________
Last school Attended ____________________________________________________________________________
Current School ___________________________Grade ______ Birth date _____________ Exceptional children services
Yes No
Temporary Permanent Address ______________________________________________________________
City/State ________________________________ ZIP Code ___________ Home Phone______________________
Name of Parent(s)/Legal guardian(s) _______________________________________________________________
Address ______________________________________________________________________________________
(Complete if not the same as above)
City/State ________________________________ ZIP Code ___________ Home Phone______________________
Mother/Guardian Place of Employment ______________________________ Work Phone____________________
Father/Guardian Place of Employment _______________________________ Work Phone____________________
Emergency Contact _______________________________________________Phone ________________________
Emergency Contact _______________________________________________ Phone ________________________
Name(s) of school-age sibling(s)/grade(s)/school(s) attending: __________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Student’s living arrangement is:
Sharing the housing of other people due to loss of housing due to economic hardship, fire, etc
Living in a motel, hotel, trailer park (transient) or camping ground due to lack of alternative accommodations
Living in emergency shelter or transitional housing; are abandoned in the hospital or awaiting foster care
placement (Note: an example would be Salvation Army, ABCCM Women and Children’s Shelter)
Living in a car, park, abandoned building, substandard housing, bus or train station, etc.
Unaccompanied youth or runaway
Please check one:
I wish to have my child continue in his/her current school for the remainder of the current school year.
School of Origin ________________________________________________________________________
I wish to enroll my child in the new school for the address at which I am currently staying.
School of Residence _____________________________________________________________________
Please check the following educational and student support services this child is enrolled in/receiving:
Exceptional Children Section 504 English as a Second School
Other(s):
Language
Counseling
Mental Health
Academically
Intellectually Gifted
and Talented
Career Technical
Education
Social Work None
Please check records needed (lack of documentation is not a barrier to enrollment):
Immunization or Medical records Guardianship Records Birth Certificates
Academic Records Evaluations for Special Programs Other:
Please note any barriers to the enrollment and the success of this child: ____________________________________
_____________________________________________________________________________________________

Rev. 10/2010
Notes:
Please check any of the following education support services the student may need:
Transportation
Clothing to meet school requirement
Free School Breakfast and Lunch Program
School supplies
Assistance with school enrollment
Obtaining/transferring records for enrollment
Emergency assistance related to school attendance Assistance with participation in school programs
Referrals for medical, dental, other health services Before/after-school care, mentoring, summer programs
Referrals to community agencies
Early childhood programs
Parent ed. related to rights/resources for children Addressing needs related to domestic violence
Counseling (i.e. Mental Health, etc.)
Coordinating schools and agencies
Expedited evaluations
Adult Education Program
Tutoring or other instructional support
Other (specify)
________________________________________________________________________________________________
______________________________________________________________ (attach further information, if necessary).
→ PARENT/GUARDIAN/CARETAKER STATEMENT:
I understand that this application pertains to the child’s placement in Asheville City Schools for the current school year only.
I further understand that if the information provided is false, the child may be removed from the school. The district will give
notice of an opportunity to appeal the removal in accordance with district policy and applicable laws.
I understand that, if I have provided false information in this application, I may have to pay the Asheville City Schools an
amount equal to the cost of educating the child.
→ Parent/Legal Guardian/Caretaker Signature: _________________________________ Date ________________
→School Witness Signature: _____________________________________________________ Date _________________
(Witness must be a school employee and must follow the distribution procedure below.)
School Witness: Please complete the information below and immediately distribute copies via fax, in person, or by courier to the
(1) ACS Student Services, (2) school SOCIAL WORKER, and (3) school COUNSELOR.
SCHOOL WITNESS
Please start below to distribute
this form in the order indicated.
(1) Witness, please clearly print your name, title/role, & school below:
SENT VIA
(Specify:
Fax/Courier
Mailbox/
In person/Other)
DATE
SENT
FOR
STUDENT SERVICES
USE ONLY
CHILD NUTRITION
NOTICE SENT TO
DATE
SENT
C
h
e
c
k
√
Witness:_______________________________________________
Child Nutrition
Next
(2) Notify ACS Student Services
(the Homeless Liaison) and
Send or deliver ORIGINAL to
ACS Student Services
@ 85 Mountain Street
Phone: 350-6160
Fax: 255-5131
Social Worker
School Data Manager
(3) Copy to School Social Worker
(4) Copy to School Counselor
(5) Copy to School Data Manager
Print Name & School
Print Name & School
Print Name & School
(6) Copy to Homebase Coordinator Print Name & School
Other:
NCWISE Coordinator
Homebase Coordinator
Other: