CAREGIVER’S AUTHORIZATION
FOR UNACCOMPANIED YOUTH
This authorization is intended to address the McKinney-Vento Homeless Education Assistance Act of 2001
(P.L. 107-1100 requirement that homeless children are to have access to education and other services. The
McKinney-Vento Act specifically states that barriers to enrollment must be removed.
The student named below lives in my home, and I am 18 years of age or older.
Student Name: ___________________________________
Date of Birth: ____________________
My Name (adult with whom student is living): ________________________________________________
Home Address: ______________________________________________
______________________________________________ Phone: ____________________
Place of Employment: _________________________________________ Phone: ____________________
_____ I am a grandparent, aunt, uncle, or other qualified relative of the minor state
relationship:___________________
_____ I am not related to this minor
Check one or both (for example, if one parent was advised and the other could not be located):
_____ I have advised the parent(s) or other person(s) having legal custody of the minor as to my intent to
provide care and housing and have received no objection. State person(s) notified: _________________
_________________________________________________________________
_____ I am unable to contact the parent(s) or legal guardian(s) at this time to notify them of my intent to
provide care and housing. State name of person(s) with who contact was attempted: ________________
_________________________________________________________________
I state that the foregoing information is true and correct to the best of my knowledge.
________________________________________
Signature
_____________________________
Date
Fax or send a copy of this form through courier to District McKinney-Vento Liaison, Tonya Reid