Iredell-Statesville Schools
McKinney Vento Verification for Food Services
This form replaces the application for free lunch for students certified as McKinney Vento by the school or district-level
liaison
_____ Initial Entry for M-V free lunch
_____Exit from M-V free lunch
M-V entry date: _______________
M-V exit date: _______________
Students Name: _________________________ PowerSchool #______________ DOB: ________
Current School: ________________________________________
Current Grade: _____________
Current Address ___________________________________________________________________
Type of Residence: (shelter, motel, etc. ) ________________________________________________
Parent/Guardian Name(s): ___________________________________________________________
__________________________________________
Signature of School Based McKinney - Vento Liaison
___________________________
Date
**SCHOOL BASED MCKINNEY-VENTO LIAISON KEEPS A COPY**
**COPY GIVEN TO SCHOOL BASED CAFETERIA MANAGER**
Fax or send a copy of this form through courier to District McKinney-Vento Liaison, Tonya Reid. Fax to
Child Nutrition (Joan Newland) 704-873-5640