__________SY		_________  County Schools 
STATE OF NORTH CAROLINA	Student in Transition Affidavit ____________ COUNTY

1.	I am the parent/legal guardian of

USE SEPARATE FORM FOR EACH CHILD

(Student’s name)  	

If the student is currently enrolled in ________County Schools, place the student ID number here:    	                      

ETHNICITY: (Must select one)	Hispanic/Latino	Not Hispanic/Latino

RACE: (Must select at least one)	Black or African American	Asian	White American Indian or Alaska Native	Native Hawaiian or Other Pacific Islander

Age  	

Date of Birth

Gender	Female  Male
Circle One

/_	/_

The child’s current school is  	

Grade Level for Current Year 	

Does the student have special education needs?	If yes, what are they?  	
2.	My name is  	
I am currently staying at this address:

Street  	

					

City/State	ZIP

I have been staying at this address since

 	/ 	
Month	Year

I get my mail at  	

Phone number where I can be reached   	

Work number (if applicable)  	

If staying at a shelter, list name and phone number of agency contact  	

Please list all children living with you under age 21 and currently not enrolled in school or has not graduated high school.
Enter additional LEA notations, if needed.	
Last Name	First Name	Middle Name	Gender	Birthdate	Grade	Relation to You	

							

3.	Please check one:
q I wish to have my child continue in his/her current school for the current school year.
Current School  	
q I wish to enroll my child at the new school for the address at which I am currently staying.
New Attendance Zone School  	
q (Only effective after the first day of school)  I have now become permanently housed but would like for my child to complete the school year at the current school. (If this item is checked, skip the next section 4, and continue to second page.   Current School  	
4.	I meet the definition of homeless as detailed in the McKinney-Vento Act, reauthorized in 2015 under ESSA because (check one):
If completed by the parent/legal guardian, check one:
q My child and I live with a friend, relative or someone else because we lost our home or housing. 
q My child and I are staying in a hotel, motel or campground due to lack of adequate alternative accommodations. 
q My child and I are living in an emergency shelter, transitional shelter or a domestic violence shelter. 
q My child and I have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a
regular sleeping accommodation for human beings. 
          If completed by the student (unaccompanied youth), check one:
q I, the student, live with a friend, relative or someone else because I am a runaway, have been told to leave home, or have been abandoned by my parents/legal guardian. 
q I, the student, stay in a hotel, motel or campground due to lack of adequate alternative accommodations because I am a runaway, have been told to leave home, or have been abandoned by my parents/legal guardian. 
q I, the student, live in an emergency shelter, transitional shelter or a domestic violence shelter because I am a runaway, have been told to leave home, or have been abandoned by my parents/legal guardian. 
q I, the student, have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a
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regular sleeping accommodation for human beings because I am a runaway, have been told to leave home, or have been abandoned by my parents/legal guardian. 

5.	I understand that this form pertains to the child’s placement in  _____________ School only for the current school year. I also understand that if I remain in transition, a new copy of this affidavit must be completed with the school each time I move to a different transitional housing situation.
6.	I understand that if the information on this form is false, the child may be removed from the school. The district will give notice of an opportunity to appeal the removal in accordance with the district policy. I understand that providing false information on this affidavit is a federal offense.
7.	TRANSPORTATION INFORMATION

If transportation IS needed for your child, please complete the section below.

TRANSPORTATION TO SCHOOL IS REQUESTED FROM (where child will be picked up in morning):

ADDRESS  	

(If this is a childcare facility, include the name, address and telephone number of the facility)

TRANSPORTATION FROM SCHOOL IS REQUESTED TO (where child will be taken after school):

ADDRESS  	

(If this is a childcare facility, include the name, address and telephone number of the facility)

If transportation IS NOT needed for your child, please complete the section below.

 	 I DO NOT NEED TRANSPORTATION FOR MY CHILD TO OR FROM SCHOOL.
(please initial)

8.	Parent Signature	Date