Sep 20, 2017 - Federal Property(s) where Parent/Guardian listed above works. (Please check one for each parent/guardian.
Please return completed form by Monday, September 25, 2017
MADISON COUNTY SCHOOL DISTRICT IMPACT AID PARENT-PUPIL SURVEY
Please provide all information as of the OFFICIAL SURVEY DATE, September 20, 2017. PLEASE COMPLETE A SEPARATE FORM FOR EACH SCHOOL AGE CHILD. I. STUDENT INFORMATION
Student’s Last Name
First Name
MI
Home Address (complete)
Date of Birth
City
Grade
School
State
Zip Code
Please complete the information to the right on each child. Other Children
II. ADDRESS Is the address in box I on Federal Property (Military Housing/US Housing Authority?)
[] Yes
If yes, please check one.
Date of Birth
[] Military Housing on Redstone Arsenal [] Gurley Gardens [] Farm Labor Housing [] Migrant Labor Housing
School
Grade
Same Address? Y N N Y N Y Y N
[] US Housing Funded under the Housing Act of 1937 [] Other
[] No NAME of PARENT/GUARDIAN working on Redstone Arsenal or other Federal Property listed below.
III. PARENT INFORMATION Was mother, father, stepmother, stepfather, or legal guardian, with whom the student resides, employed on Federal property anywhere in Alabama on September 20, 2017?
[] Yes
[] No
IV. UNIFORMED SERVICES Was either parent/guardian an active duty member of the uniformed services on September 20, 2017?
[] Yes
If yes, please provide name of parent and his/her employer’s complete name and address in the spaces provided.
[] No
If yes, please check one AND write the name of parent on active duty and list their rank.
Name
Name
Name of Employer:
Name of Employer:
Address Where Parent/Guardian Reports to Work:
Address Where Parent/Guardian Reports to Work
Street :
Street:
City:
ZIP:
City:
ZIP:
Federal Property(s) where Parent/Guardian listed above works. (Please check one for each parent/guardian.) [] Redstone Arsenal, AL (Bldg: # ) [] NASA-Marshall Space Flight Center (Bldg: # [] Anniston Army Depot [] Army Reserve, Patton Road [] Browns Ferry, Athens [] FAA Air Traffic Control Tower [] Federal Buildings and Courthouses [] Guntersville Dam /Reservoir [] Maxwell Air Force Base [] Other Federal Property in Alabama
)
[] Naval Reserve Training Center [] TVA Power Service Center, Farley [] TVA Power Service Center, Guntersville [] TVA Power Service Center, Huntsville [] TVA Power Service Center, Muscle Shoals [] TVA Power Service Center, Scottsboro [] TVA Power Service Center, Widows Creek [] TVA Power Service Center, Woodson
PARENT INCLUDES: Father, Mother, Stepfather/mother, or Legal Guardian. ACTIVE DUTY UNIFORMED SERVICES INCLUDE: Parents on ACTIVE DUTY in the Army, Air Force, Navy, Coast Guard, Foreign Military, National Guard or Reserve. (If National Guard, or Reserves please provide a copy of orders) NAME RANK (Required) [] US ARMY [] US Navy [] National Guard Title 10 [] Other
[] US Marine Corps [] US Coast Guard [] National Guard Title 32
[] US Air Force [] Foreign Military
NOTE: Those listed must be on active duty in the Uniformed Services of the United States as of September 20, 2017.
V. SIGNATURE AND DATE
By signing this form, I certify that the above information is true and correct as of September 20, 2017.
Please sign and date.
Signature of Parent/Guardian
Date
Must be signed and dated on or after September 20, 2017, to be accepted.
