PWCS McKinney-Vento Eligibility Form

Welcome to the PWCS MKV Eligibility Form 2023-24 School Year

The PWCS McKinney-Vento (MKV) program provides the following educational rights and benefits to students who meet the homeless definition. The overall goal of McKinney-Vento is to remove enrollment barriers and offer school stability during a time of housing instability.

Students who qualify receive ...

Immediate school enrollment/attendance with enrollment barriers being removed ...
- No residency proof required for purposes of enrollment
  - Note: In some situations, the PWCS MKV Liaison might request information
- Student can enroll/attend without producing birth certificate, physical and/or immunization record)
  - Birth certificate will need to be provided to the school office within 90 days of enrollment per PWCS regulation. Schools may request that a Birth Certificate Affidavit be completed at time of immediate enrollment which is permissible. Schools cannot require that the affidavit be notarized.
  - Immunizations/physical must be produced to the school office within 60 days of enrollment per PWCS regulation.
Automatic approval for free school meals for the school year
Participation in school activities
- Note: The MKV program is not required to provide afterschool transportation services.
Option of remaining in same school (if determined to be in the student's best interest) even if the student/family move outside of school boundaries and/or into permanent housing during the school year in which the student qualifies for MKV
School transportation (when determined to be feasible by MKV Liaison) for students to remain in the same school (school of origin) while residing outside of school boundaries (during the school year in which the student qualifies for MKV)

To learn more about the PWCS MKV program and the definition of homelessness, consult our website: PWCS MKV Program

The information that you provide on this MKV Eligibility Form helps the PWCS McKinney-Vento (MKV) Liaison to gather the details of the student's housing/family story in order to determine if the situation meets the MKV definition for homelessness. Additional information may be requested. Each student is assessed case-by-case. If a student is approved for the MKV program, the status is valid only for the school year in which the student qualifies.  The MKV status is confidential. If you encounter any challenges with completing/submitting this form, email the MKV Liaison, Tami Eppolite at EppoliTF@pwcs.edu. (This form is available in English and Spanish with more translations coming soon ... to access the Spanish version, click on the word "English" on top right-hand corner of form and a drop-down menu will appear.)

Please complete the following questions for the student(s) to be considered for the PWCS McKinney-Vento Program for 2023-24 ...

TODAY'S DATE *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

STUDENT 1

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

Choose the local/zoned school from the drop-down menu below which serves the address where the student is residing the majority of the school nights: *This question is required.
Since this student is new to PWCS or is a returning student to PWCS (after being withdrawn and attending a different school district), the student needs to enroll in the school that is zoned for the address where the student is residing. You can use our PWCS Find My School (PWCS Find My School (based on address) to determine the local/zoned school.

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

What is your school preference for this student for 2023-24? MKV gives only two school options (choose one): *This question is required.
NOTE: School placement will be made according to the student's best interest which is determined by the MKV Liaison. If a student is involved with the Hearings Office and/or has an IEP (special education needs), those programs determine school placement which MKV does not override.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 2 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 3 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 4 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 5 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 6 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 7 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

STUDENT 8 *This question is required.

Student's First Name *This question is required.

Student's Last Name *This question is required.

Student's Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar MM/DD/YYYY

Is the student NEW to PWCS or RE-ENROLLING in PWCS (after being withdrawn and attending a different school district) for the 2023-24 school year? *This question is required.

Where and when was this student last enrolled in school? *This question is required.

Name of Previous School
Location of Previous School (city/county & state)
Approximate End Date of Last Enrollment

What is the name of the school that this student is currently enrolled in for 2023-24 in PWCS? *This question is required.

(2nd Option) ... School of Origin
A school of origin is the last school attended when permanently housed or the school in which the student was last enrolled when identified as homeless by PWCS.  When a student attends a new school, it becomes their school of origin for future purposes.  A feeder school of origin is the school that the student's peers are rising up to from elementary to middle or middle to high school. If there are multiple feeder schools, then there might not be a feeder school of origin.

PWCS ID Number *This question is required.

unknown? enter 0

Are there school-aged siblings who are also in the same housing situation? *This question is required.

If there are younger siblings (NON school aged) in the family in the same housing situation, please list their names and ages:

1st Child's Name & Age:
2nd Child's Name & Age:
3rd Child's Name & Age:
4th Child's Name & Age:

CONTACT INFORMATION *This question is required.

First Name of Parent/Custodian/Caregiver/HUY Student *This question is required.

Last Name of Parent/Custodian/Caregiver/HUY Student *This question is required.

Which of the following best describes the relationship to the student(s): *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

What is the preferred language for communication for the parent/custodian/caregiver/HUY Student? *This question is required.

Please enter an 'other' value for this selection.

Email Address of Person Listed Above (Parent/Custodian/Caregiver/HUY Student) *This question is required. NOTE: This is the preferred method of communication with the MKV Staff and Transportation Team. If you do not have an email address, please use an alternative email such as the student's PWCS email or a friend or family member's email address. This question requires a valid email address.

ex: email@pwcs.edu

Comments

Phone Numbers of Person Listed Above (Parent/Custodian/Caregiver/HUY Student) *This question is required.

Cell Phone
Work Phone
Home Phone
NO Phone (put an "x" in this box):

If a cell phone was provided ... *This question is required.(check all that apply)

The cell phone CAN RECEIVE texts from PWCS Staff
The cell phone CAN RESPOND to texts from PWCS Staff
NO texting ability
No cell phone

CURRENT ADDRESS OF STUDENT(S)

Street Number & Street Name *This question is required. (include room/suite/unit number if applicable)

City *This question is required.

Zip Code *This question is required. This question requires a valid number format.

If you have a housing or agency case manager, supply their contact information below:

Case Manager's Name:
Case Manager's Agency Name:
Case Manager's Phone:
Case Manager's Email:

Who completed this form?
(If you are completing the form on behalf of someone, please be sure that they are aware.) *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

Does the student's housing/family situation possibly qualify as a MKV Homeless Unaccompanied Youth (HUY)? *

A MKV HUY student meets the MKV definition for homeless and the STUDENT is NOT residing with his/her parent or court appointed legal custodian due to reasons of hardship.

*This question is required.

A MKV HUY student might be doubling up with friends/family, staying in a hotel/motel/shelter, couch surfing or possibly unsheltered. A MKV HUY student might have chosen to leave their parents/custodian's home due to hardship or could have been asked to leave their parents/custodian's home due to reasons of hardship. Some MKV HUY students might not have the option to reside with their parent/custodian for a variety of reasons/hardships. A HUY student's age can range from early childhood (preschool/headstart) through the age of 21 years old (12th grade).

Link to MKV/HUY Definition: Homelessness - Prince William County Public Schools (pwcs.edu)

If more than one student is listed on this form, specify which student(s) might qualify for Homeless Unaccompanied Youth (HUY) status?

Are the MKV HUY student's parent or court appointed legal custodian aware of the whereabouts of the student? *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

Being that the MKV HUY student does not reside with their parent or court appointed legal custodian, explain the whereabouts of the parent or legal custodian? *This question is required.

Explain why the student is not residing with the parent or court appointed legal custodian (i.e., what is preventing the student from residing with parent or legal custodian)? *This question is required.

Choose one of the options below which best describes the current temporary housing situation? *This question is required.Students in shelter, transitional housing and unsheltered automatically qualify for McKinney-Vento.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

Copy of Hotel/Motel Receipt can be Uploaded Here

File: {{filename}} delete

Explain the student/family's housing journey ... including but not limited to:

Where was the student/family residing previously?
What happened to the previous housing situation that resulted in a loss of housing?
What does the current temporary housing situation look like?
What hardships resulted in the temporary housing situation?

*This question is required.

What were the contributing factors to the student/family's previous loss of housing which resulted in the current temporary housing situation? (Note: There must be a hardship which resulted in the unexpected loss of housing.) *This question is required.

Domestic Violence
Natural Disaster
Humanitarian Crisis in Home Country
Uninhabitable Living Conditions in Home
Health/Medical Issues
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

McKinney-Vento assesses whether the student's current temporary housing situation is fixed and regular and adequate ... answer the questions below to help the MKV Liaison assess those aspects *This question is required.

FIXED = permanent, not subject to change;
REGULAR- = used on a regular basis;
ADEQUATE = sufficient

Space Cell	Yes	No	Unsure
Is there a possibility that the student/family could be asked to leave at anytime?	Is there a possibility that the student/family could be asked to leave at anytime?: Yes	Is there a possibility that the student/family could be asked to leave at anytime?: No	Is there a possibility that the student/family could be asked to leave at anytime?: Unsure
Is the student/family searching for another place to live?	Is the student/family searching for another place to live?: Yes	Is the student/family searching for another place to live?: No	Is the student/family searching for another place to live?: Unsure
Does the student/family go home to the same housing situation every night?	Does the student/family go home to the same housing situation every night?: Yes	Does the student/family go home to the same housing situation every night?: No	Does the student/family go home to the same housing situation every night?: Unsure
Is the student/family guaranteed to stay at the same place every night?	Is the student/family guaranteed to stay at the same place every night?: Yes	Is the student/family guaranteed to stay at the same place every night?: No	Is the student/family guaranteed to stay at the same place every night?: Unsure
Are the conditions of the current housing situation over-crowded?	Are the conditions of the current housing situation over-crowded?: Yes	Are the conditions of the current housing situation over-crowded?: No	Are the conditions of the current housing situation over-crowded?: Unsure
Does the student/family feel safe in the current housing situation?	Does the student/family feel safe in the current housing situation?: Yes	Does the student/family feel safe in the current housing situation?: No	Does the student/family feel safe in the current housing situation?: Unsure
Are the conditions of the current housing situation in good condition?	Are the conditions of the current housing situation in good condition?: Yes	Are the conditions of the current housing situation in good condition?: No	Are the conditions of the current housing situation in good condition?: Unsure
Does the student/family have access to the kitchen and bathroom at any time?	Does the student/family have access to the kitchen and bathroom at any time?: Yes	Does the student/family have access to the kitchen and bathroom at any time?: No	Does the student/family have access to the kitchen and bathroom at any time?: Unsure
Is there heat, electricity and water available in the current housing situation at all times?	Is there heat, electricity and water available in the current housing situation at all times?: Yes	Is there heat, electricity and water available in the current housing situation at all times?: No	Is there heat, electricity and water available in the current housing situation at all times?: Unsure

How long did the student/family reside in the previous housing? *This question is required.

How long has the student/family been residing in the current housing situation? *This question is required.

How long is the student/family able/permitted to reside in the current housing situation? *This question is required.

How many people are residing in the current housing situation? *This question is required.

Where is/are the student(s) sleeping at night in the current housing situation? *This question is required.(check all that apply for the students in the situation)

Bed or Air Mattress - in common space area
Bed or Air Mattress - in private room or room shared with immediate family
Couch - in common space area
Couch - in private room or room shared with immediate family
Floor - in common space area
Floor - private room or room shared with immediate family
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

If the student/family are temporarily doubled-up due to hardship, who is the host home provider?
OPTIONAL - We never want to jeopardize the host home provider's situation so please do not give out information that could put their housing at risk.

Host Home Provider's Name:
Host Home Provider's Address (street number/name):
Host Home Provider's Address (city/state/zip):
Host Home Provider's Email
Host Home Provider's Phone:

Describe the student/family's future housing plans, including time frame: *This question is required.

Check all of the services below that the student needs (if none, check the last box) ... *This question is required.Either our MKV social worker or the school-based social worker will be in touch with the student/family via email.

The student needs school supplies and/or backpack
The student needs school clothing and/or shoes
(Please note that community resources for these items are generally gently used.)
The student needs food resources.
(The PWCS MKV Office can provide a list of community resources for the family/student to access.)
The student needs medical resources.
(The PWCS MKV Office will attempt to provide a list of community resources for the family/student to access.)
The student needs mental health resources.
(The PWCS MKV Office will attempt to provide a list of community resources for the family/student to access.)
The student/family needs assistance with learning about housing resources.
(Please note that the PWCS McKinney-Vento Office does not have housing to offer but we can provide guidance to possible community housing resources and websites as they become available.)
If there is a need that is not listed, write-in here and the PWCS MKV Office will do their best to assist in locating possible resources: Please enter an 'other' value for this selection. * This question is required.
NO services are requested at this time.

Our MKV office receives information about community resources (i.e., job fairs, free food giveaway events, free/reduced medical/dental events, etc) on a routine basis. Would you like for us to pass that information on to you via email as it comes in?
*This question is required.

Will you be requesting school transportation services for any of the students listed on this form?

After you submit this form, the "thank you" page will appear and it will provide you with the link to the 2023-24 McKinney-Vento Transportation Form. Be sure to complete and submit that form if the situation meets one of the reasons listed above as to why MKV would set up special transportation services.

IMPORTANT INFORMATION REGARDING MCKINNEY-VENTO ...

Determination of homelessness (as defined by McKinney-Vento) is based on the consideration of the permanence and adequacy of the living situation, and is always individually reviewed on a case-by-case basis by the McKinney-Vento Liaison.

Any person making a materially false statement regarding residency in a school division may be guilty of a Class 4 Misdemeanor and may be liable to the school division in which the student was enrolled as a result of such false statements for tuition charges, pursuant to the Virginia Code §22.1-5, for the time the student was enrolled in such school division.

The student's McKinney-Vento status is valid only for the school year in which the student is approved. A student/family must re-apply or contact the McKinney-Vento Office to be re-assessed for the next school year's MKV program if the student's housing situation appears to be temporary due to hardship.

MKV approved students have the rights to the following ...

Students do not need a permanent address or residency proof to enroll in school.
Students cannot be denied school enrollment when school records or other enrollment documentation are not immediately available.
Students may be able to remain in the same school (school of origin) even if the student moves outside of school boundary or into permanent housing during the school year.
If the MKV Liaison determines it to be in the student's best interest, he/she has the right to transportation services (if deemed feasible) to and from the school of origin.
Students automatically qualify to participate in free meal programs while in school.
Students have the right to participate in extracurricular activities and all federal, state, or local programs for which he/she is eligible.

MCKINNEY-VENTO HOMELESS EDUCATION SERVICES AGREEMENT ...

I (person completing this form) certify that all of the information provided on this eligibility application is accurate to the best of my knowledge.
The parent/custodian/caregiver/HUY student are aware that approved student(s) will receive MKV services/transportation through the remainder of the given school year even if the student/family obtain permanent housing.
The parent/custodian/caregiver/HUY student understand that it is the parent/custodian/caregiver/HUY student responsibility to update the school office with any changes in address or contact information. The parent/custodian/caregiver/HUY student will provide the school with a good mailing address which might not be the address where the student/family is residing due to reasons of confidentiality or risking others housing situation.
The parent/custodian/caregiver/HUY student understand that the student(s) has the right to participate in extracurricular school activities which includes sports; however, the McKinney-Vento Act does not explicitly require that transportation be provided to/from extracurricular activities.
The parent/custodian/caregiver/HUY student understand that if the student(s) does not maintain regular/on-time attendance, good academic performance and/or exhibit good behavior in school on a regular basis, a best interest determination meeting may be held to discuss transferring to the school that is zoned for the student's residence. I also understand that I would have the right to appeal a decision and the MKV Liaison will supply me with that information if requested.
The parent/custodian/caregiver/HUY student understand that a false claim of homelessness or false residency information may result in the withdrawal of my student from school.

Is there any additional information that you would like to share with the MKV Office Staff?

RESPONSE TO THIS FORM WILL BE SENT VIA EMAIL
(please watch your email inbox along with your email spam/junk boxes)

Signature of Person Completing this Form (which can be parent//custodian/caregiver/HUY student OR school staff or housing/agency staff on behalf of the family): *This question is required.

Clear

Signature of

CLICK ON THE SUBMIT BUTTON ONCE THE FORM IS COMPLETE

PWCS McKinney-Vento Eligibility Form - 2023-24 School Year

Welcome to the PWCS MKV Eligibility Form 2023-24 School Year