Please fill out this questionnaire. Leave this field blank Name of Child Date of Birth Name of Parent/ Guardian Families who are currently living in temporary housing are eligible to receive priority for Head Start services and enrollment. For the purpose of your enrollment application to determine if your family is in temporary housing, please check the box that indicates your current living situation. The answer you give will be kept confidential and will only be shared with staff providing services to your child and for tracking of how many children in Head Start are in temporary housing. We live in transitional housing and must move out of this housing within two years. We live with friends, family or someone else because we lost our home or cannot afford a home (also called “doubled-up”). We move around frequently staying with various friends, relatives, or others. We are staying in a motel or hotel because we lost our home or cannot afford a home. We are staying at a homeless shelter or domestic violence shelter. We are sleeping at night in a building or home that is not meant for people to sleep in (this includes condemned homes or homes that do not have necessary services such as heat or water, garages, barns, parks, public place, abandoned building, bus or train station). We are camping in a tent, motor home, travel trailer, van, car or other vehicle. We do not have a place to sleep at night. In permanent housing/none of the above apply If you indicated staying in a homeless shelter or domestic violence shelter please provide the name of the shelter. (optional) Parent/ Guardian Signature: Start drawing Clear Done Start over Date of Signature: Send
