HOMELESS PROGRAM Student Transportation Request Form

HOMELESS PROGRAM Student Transportation Request Form

HOMELESS PROGRAM
Student Transportation Request Form
To be completed by the district homeless liaison:
Campus Name:
Name of Student:
Sex:
ID Number:
Male
Female
Date of Birth
Age:
Where is the student living? (Check one box)
In a Motel
In a Shelter
Other
(please explain):
Provide transportation from:
Home to School
Signature Field
School to Home
Residing location address:
Residing location phone:
Name of parent(s), legal guardian(s):
Transportation requested by parent/guardian to comply with school of origin guidelines.
Signature of District Representative:
Date
*San Elizario Independent School District does not discriminate on the basis of race, color, religion, sex, national origin, age or disability in its programs, activities or employment.
El Distrito escolar de San Elizario no discrimina en base a raza, color, religion, sexo, nacionalidad, edad y/o discapacidad en sus programas, actividades, o empleo.
11/2015
Homeless Trans. Form