St. Lucie Public Schools
Student Residency Information
This survey is intended to address the requirements of the No Child Left Behind Act: Title X/ Part C, and Title I/Part A. PLEASE PRINT
CLEARLY, COMPLETE ONE PER FAMILY, and return the survey to the Student Assignment Office located at 4204 Okeechobee Rd.
Fort Pierce, Fl. 34947 or at a school. ¿Habla Ud. Español? Por favor doble este papel al otro lado para llenar este estudio.
Please list students in the household enrolled in school (PK – grade 12) or Adult School (If needed, use an additional sheet of paper.)
__________________
Student ID
__________________
Student ID
__________________
Student ID
__________________
First Name
__________________
First Name
__________________
First Name
___________________
Last Name
___________________
Last Name
___________________
Last Name
__/__/____
Birth date
__/__/____
Birth date
__/__/____
Birth date
____
Grade
____
Grade
____
Grade
____________________
School
____________________
School
____________________
School
How many other children are in your household (even if not enrolled in school)? ____________
Parent/Guardian Name (Print): ____________________________________________Relationship to Student:_______________
Parent/Guardian Name (Print): ____________________________________________Relationship to Student:_______________
Street Address (Location of House): __________________________________________________________________________
Street
Length of time at current address: __________
City
State
Zip
Is this a temporary living arrangement? _____Yes ______No
Mailing Address (If different): _______________________________________________________________________________
Street
City
State
Zip
Telephone: ________________________ Cell phone: ________________________ Work phone: ________________________
Former Address: __________________________________________________________________________________________
Street
City
State
Zip
Check (1) one box. Presently, are you and/or your family in any of the following situations?
[A] ____Living in an emergency or transitional shelter (Name):_________________________________________
[B] _____Living with family or friends temporarily due to our loss of housing, economic hardship or a similar reason.
[D] _____Living in a car, park, temporary trailer park, campground, public space, abandoned building, substandard housing or similar
settings.
[E] _____Living in a hotel or motel temporarily due to loss of housing, or economic hardship or similar reason.
[F] _____Awaiting foster care placement (List Case Manger’s Name & Phone#):_____________________________________
Is the student:
1.
An unaccompanied youth? ____yes _____no (youth not in the physical custody of a parent or legal guardian).
If YES, Check one box
Had to leave house/locked out of house
Parent incarceration (jail or prison)
Parent deceased
Abandoned/Safety
2.
Migrant? ____yes ____no (moves from one school district to another to work in agricultural jobs).
Check (1) one box. Cause for temporary housing or family being displaced:
Lack of affordable housing
Long-term poverty
Unemployment or underemployment
Health care
Mental illness
Domestic violence
Forced eviction, etc. (O)
Mortgage Foreclosure (M)
Flooding (F)
Hurricane (H)
Tropical Storm (S)
Tornado (T)
Fire (W)
Man-made Disaster (Major) (D)
Earthquake (E)
Natural Disaster – Other (N)
Other, reason: _______________________
SAO0039 Rev. 8/14
The questions that follow will assist in determining the child’s school of origin and whether or not transportation to the school of
origin is feasible. Please complete this section for each child in the family.
QUESTION
1. Are you requesting to remain at their current school? What is the
name of the school you are requesting?
Response
2. Why is it in the student’s best interest to remain at their current
school?
3. Do you expect the distance of the commute impact the student or
do you feel that the student’s quality of education be better served at
a local area school?
4. What is the length of anticipated stay at temporary residence?
5. Is the student receiving special education or related services?
Which service?
If student is eligible under McKinney Vento (Homeless), they have the following rights:
 Immediate enrollment into school
 School stability – continue in same school attended before loss of housing or last school attended (school of origin), if in
the student’s best interest and feasible
 Transportation – to remain at the “school of origin”, if over 2 miles
 Free lunch

Should the District determine that educating the student in the school of origin is not feasible; the parent has the right to
appeal that decision in writing to the District’s Homeless Liaison.
By signing below, I declare that the information provided is correct, I am aware that:
1.
2.
3.
I must notify my child’s school immediately should my residence change.
Anyone who knowingly makes false statements in writing with the intent to mislead shall be guilty of a misdemeanor
and is punishable as provided in Sections 777.082, 775.083, 837.06, Florida Statutes.
This determination is limited to a period of one school year, and must be reapplied for annually.
Parent/Caregiver/Unaccompanied Youth Signature: _________________________________________________Date:_________
OFFICIAL USE ONLY
____ Recertified by Phone
____ Recertified in Office/School
____ Recertified by Mail
Intake Location: _____________________________________________________________
Intake Person’s Name & Title: _________________________________________________________________ Date: _____________________