2023-2024 Project ACT Parent/Caregiver Homeless Enrollment Form

Welcome to Project ACT. We are here to assist you. Please complete all questions on the form.

For each student to be enrolled today, you will need to complete an individual form. Once you have completed a form for each of your children, please take a seat, and you will be called to see a staff member in order in which you have arrived.

Today's Date

mm/dd/yyyy

How can we help you today?

Select the statements that best describe your present housing situation.

Your name (Last, first)

Name of Guardian/Caregiver

Are you the Legal Guardian of the student you are enrolling?

Yes

Current address

Address where the student is staying? Please be sure to include the Zip Code!

Please provide the names of the person(s) you are staying with.

Please provide the phone number of the person(s) you are staying with.

Please provide your cell phone or contact number

Please provide your E-Mail

Immediately prior to going to your current address, were you evicted?

Have you been recently evicted?

Yes

Emergency Contact (Last, First)

Emergency Contact Phone

I am a veteran

I was once in Foster Care

I aged out of Foster Care

Student Last Name

Student First Name

Student Address

If different from above

Student Phone

If different from above.

Grade

Grade the student will be in during the 23-24 School year

Gender

Male

Female

Birthdate of student

mm/dd/yyyy

Birth City of Student

Birth State of Student

Age of student

Race of student

Classroom Type

Select regular classroom if student is not in Special Education/Gifted Education

Does the student have a 504 Plan or medical plan?

Yes

Is the student currently expelled or suspended from any school in Ohio?

What language is spoken in the home?

School Of Origin

Select the last school the student attended.

Grade

First CMSD School Choice

Which school would you like the student to be enrolled in for the 23-24 School Year?

Second CMSD School Choice

Third CMSD School Choice

Beech Brook

Please select the box below if you are interested in counseling services for your student.

Staff Interaction

I give Project ACT Staff permission to interact and work with my student at a school or shelter.

Picture Permission

May we take pictures of your child interacting in their classroom or other Project ACT Activities?

Yes

Text permission

Check this box to give CMSD permission to text to your cell phone number.

Children Birth - age 2

How many children do you have age two or younger?

Ages 3 - 5

How many children do you have ages three to five NOT including children enrolled in Kindergarten or preschool.

File Upload

Please attach all documentation in your possession: Birth Certificate, Shot Records, Special Education (IEP & ETR) Documentation, out of district report card/transcript, etc.

You MUST attach your Photo ID. We cannot process enrollment without your Photo ID attached!

Drop your files here

I agree to contact Project ACT when I move to another location

I swear/affirm that the statements in this form are true to the best of my knowledge and belief.

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