Example Forms and Documentation


WIAA Homeless Eligibility Form

Local Use Form Homeless Student Identification (PI-Q03-8)

Example Documents Created by DPI

Examples of Forms and Documents Created by Districts

This section provides examples of various forms created by districts. These forms are not required by DPI. Rather, they are tools districts can use to improve McKinney-Vento services.

     Sample District Policy and Procedure for McKinney-Vento: Appleton School District
     The Appleton Area School District's homeless policy and procedure.

District Homeless Policy and Procedure
The Tomahawk School District's homeless policy and procedure.

Student/Family Residence Questionnaire
The Madison Metropolitan School District has developed a Student/Family Residence Questionnaire form to determine eligibility for services.

Transitional Education Service Plan
The Middleton/Cross Plains School District has developed a transitional education service plan form to keep track of homeless students.

McKinney-Vento Homeless Referral Form
This form was developed by Cooperative Educational Service Agency (CESA) 11.

School of Origin Request Form
Created by Cobb County Schools, Atlanta, GA

School District of Janesville’s Personal Service Contract
Janesville contracts with an individual to provide transportation for preschool and elementary students who are homeless. Janesville has been able to eliminate the use of taxicabs. This contract is between the school district and the individual who provides transportation.

Madison Metropolitan School District’s Homeless Transportation Agreement form
This form can serve as model for coordinating transportation in your district.

Middleton-Cross Plains Area School District’s Transportation Inter-district Agreement
Middleton’s agreement can serve as a model for a transportation agreement.

Middleton-Cross Plains Area School District’s Parent Transportation Contract

Ashwaubenon Gas Card Agreement

Ashwaubenon Voluntary Survey
Ashwaubenon School District, 2009. This survey can be completed upon enrollment to help district staff determine if a student is eligible for McKinney-Vento services.

Self Identification Form for Homeless and Highly Mobile Students
Minneapolis Public Schools, 2007.

Shawano School District: Student Residency Questionnaire

School Selection Form
This form was created by CESA 11.


For questions about this information please contact one of our State EHCY Coordinators: 

Kristine Nadolski (608) 267-7338

Susan Piazza (608) 267-1284