2022-23 Pasadena Unified Housing Questionnaire

Pasadena Unified is collecting a housing questionnaire from each student as required by state law, AB 27.

This information will help Pasadena Unified determine what services you and/or your child may be eligible for. This could be additional educational services through Title I. Part A (families with economic hardship) and/or the McKinney-Vento Act (families/students lacking stable housing).

The information provided on this form will be kept confidential and only shared with the appropriate school district and school site staff.

Impacted students have the right to:

Enroll in the school last attended or the local school where you are currently staying, even if you do not have all of the documents normally required at the time of enrollment.
Continue to attend the school of origin if requested by you and in the student's best interest.
Receive transportation to and from their school of origin.
Access to necessary special programs and services such as free meals and Title I benefits.
Receive the full protections and services provided under all federal and state law.

1. Please enter your student’s District student ID number (also called lunch ID):

If you have more than one student enrolled in Pasadena Unified, please enter the information for the oldest child first. You will be able to enter the names of additional children in the household in a later question.

Student ID numbers are printed on report cards and visible when logged into your student’s portal account. Please click for instructions on where to locate the student ID number in English and Spanish.

If you did not receive a student ID number when enrolling and are unable to locate it as described above, please enter 000000 to continue with the survey. *This question is required. This question requires a valid number format.

2. Please enter your student’s name below.
In order to help us confirm we correctly identify your student, please enter your student’s full name as it appears on the student’s birth certificate/adoption papers.
*This question is required.

Student's first name
Student's middle name
Student's last name

3. Please enter your student's date of birth below. (MM/DD/YYYY format)
In order to help us confirm we correctly identify your student, please enter your student’s date of birth as it appears on the student’s birth certificate/adoption papers.
*This question is required. This question requires a valid date format of MM/DD/YYYY.

Student's date of birth calendar

4. At which school is your student currently enrolled? *This question is required.

5. Presently, are you and/or your family living in any of the following situations?
Please check all that apply.

Staying in a shelter (family, domestic violence, or youth shelters) or Federal Emergency Management Agency (FEMA) trailer.
Sharing housing with other(s) due to loss of housing, economic hardship, natural disaster, lack of adequate housing or a similar reason (for example, renting a room(s) in another family's home).
Living in a car, park, campground, abandoned building, or other location lacking adequate accommodations such as water, electricity, or heat.
Temporarily living in a motel or hotel due to loss of housing, economic hardship, natural disaster, or similar reason.
None of the above: Living in a single-home residence that is permanent building structure.

Are you a student under the age of 18 and living apart from parent/guardian(s)?

6. Please enter the name of the parent/guardian completing this form:
This information is needed in case we need to contact you for clarification. *This question is required.

First Name

Last Name

Email Address

Phone Number

7. Are there any other children living in the household? Please list their names below.
Please provide the student ID number for any children also enrolled at Pasadena Unified Schools.

	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #	Child 2	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
Child 3	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
Child 4	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
Child 5	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
Child 6	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
Child 7	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #
Child 8	Child's First Name:	Child's Last Name	Child's birthdate:	Is the student enrolled at in Pasadena Unified?	PUSD Student ID #

8. I certify (promise) that the information provided on this form is true and accurate. I understand that the school may receive state and federal funds based on the information I provide and that the information could be subject to review. *This question is required.

Clear

Signature of