Fort Cobb

Please Fill Out The STUDENT RESIDENCY QUESTIONNAIRE (One form required per student) Below

Fort Cobb-Broxton Public Schools Student Enrollment Questionnaire

District Name: Fort Cobb-Broxton School

School Year: 2024-2025

Student Name:

Date of Birth:

SCHOOL NAME:

GRADE:

Person Completing This From:

Relation to Student:

Phone Number:

Current Address:

How long at this address?

1. Is this current address a temporary living arrangement?

Reaquired field: Yes

Reaquired field: No

2. Is this temporary living arrangement due to loss of housing, economic hardship, or domestic violence?

Reaquired field: Yes

Reaquired field: No

3. Is the student being enrolled by someone other than parent or legal guardian?

Reaquired field: Yes

Reaquired field: No

4. Is the student an unaccompanied youth (not living with a parent or legal guardian)?

Reaquired field: Yes

Reaquired field: No

5. Is the student a Foster Child or waiting for Foster Placement?

Reaquired field: Yes

Reaquired field: No

If you answered NO to ALL questions, please sign and date below. Submit the form.

I certify that the information provided above is correct and accurate.

Signature of Person Completing this form:

Date:

If you answered YES to ANY question above, please complete the remainder of this form.

Please select the option that best describes your current living situation:

A. With more than one family in a house or apartment. If yes, please complete additional answer(s) below.

B. In a motel/hotel due to lack of alternative, adequate accommodations. If yes, please complete additional answer(s) below.

C. In a shelter/transitional housing. If yes, please complete additional answer(s) below.

D. In a house, building, or trailer WITHOUT running water, electricity, or gas.

E. Living with family or friends because you are an unaccompanied youth (not living with parent or legal guardian).

F. In a car, campground, abandoned building, or other public place not intended for regular habitation.

G. Wherever I can find a place to stay at night.

If you chose option A. Number of bedrooms in the house or apartment?

If you chose A. Number of people living in the house or apartment.

If you chose B. Name of motel you are staying at:

If you chose C. Name of shelter/transitional housing agency:

Please list all children (under 21 y/o) currently living with you, including those not yet old enough for school enrollment.

First and Last Name of Child:

Relationship to Student:

DATE OF BIRTH:

GRADE:

School Name:

First and Last Name of Child:

Relationship to Student:

DATE OF BIRTH:

GRADE:

School Name:

First and Last Name of Child:

Relationship to Student:

DATE OF BIRTH:

GRADE:

School Name:

First and Last Name of Child:

Relationship to Student:

DATE OF BIRTH:

GRADE:

School Name:

First and Last Name of Child:

Relationship to Student:

DATE OF BIRTH:

GRADE:

School Name:

I certify that the information provided above is correct and accurate.

Signature of Person Completing this form:

Date:

Email a copy to

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Required Fields

FORT COBB BROXTON SCHOOLS

STUDENT RESIDENCY QUESTIONNAIRE (One form required per student)