Siskiyou County Office of Education
Education for Homeless Children and Youth
Primary Nighttime Living Questionnaire
Name of School District:___________________________________________
Where is student currently living? This information will be used to determine if the student qualifies for
any additional assistance under the No Child Left Behind Act of 2001. (Check only one box per student)
Age
Gender
Grade
More than 1
family in a
house,
apartment or
trailer
In a shelter or
transitional
housing
program
________________________________________
Superintendent/Principal Signature
With friends or
family
members
In a motel, car
or campsite
Awaiting
foster care
placement
Unaccompanied
Youth
_________________
Date
Thank you for completing this form.
We look forward to working with you to help your students be successful in school!
Siskiyou County Office of Education
Kermith Walters, County Superintendent
609 South Gold Street
Yreka, CA 96097
(530) 842-8400
www.siskiyoucoe.net