Purpose: This questionnaire is the result of a Department of Defense (DOD) program supported by Indiana statute 20-19-3-9.4. Confidentially identifying military children and providing data on their attendance and educational outcomes, states can assist schools and districts by providing access to data to help inform policy and program decisions for this unique student population. In addition, DOD will benefit from this data in developing policy for military child education initiatives.

School Name: ________________________________________ Student's Grade Level:______________

Student's Full Legal Name: ______________________________________________________________

Please print clearly

Please complete the questions that best describes your student's situation. It is possible to answer "yes" to both.

1. Is the above named student connected to an Active Duty military family: ______Yes ______No

Meaning a school-aged child, enrolled or in the process of enrolling in KG-12th grade, is claimed as a dependent by an Active Duty member of the Armed Forces of the United States; or the student and an Active Duty member(s) are of the same household whether or not the active duty member(s) claims the student as a dependent. "Active Duty" means: full-time duty status in the active uniformed service of the United States.

2. Is the above named student connected to a Guard or Reserve military family: ______Yes ______No

Meaning a school-aged child, enrolled or in the process of enrolling in KG-12th grade, who is claimed as a dependent by a member of the National Guard or Reserve; or the student and National Guard or Reserve member(s) are of the same household whether or not the National Guard or Reserve member(s) claims the student as a dependent.

"National Guard or Reserve" means: members of the Reserve Component as defined in 10 U.S.C. Section 10101. Includes Army National Guard of US, Army Reserve, Navy Reserve, Marine Corps Reserve, Air National Guard of US, Air Force Reserve or Coast Guard Reserve.

ONLY For Students of an ADULT High School (IC 20-24-1-2.3)

Is the above named student an active member of the Armed Forces of the United States ____Yes ____No

OR

Is the above named student a member of the National Guard or Reserve ______Yes ______No

Signature:____________________________________________________Date:____________________

This form shall be handled by schools in a confidential manner in accordance with IDOE Guidance (IC 20-19-3-9.4)