Yelm School District Impact Aid Program Survey

Yelm School District School:_____________________________________ Impact Aid Program Survey Survey Date: December 1, 2020 1. STUDENT INFORMATION Student’s Name: Student’s DOB: Grade: Address: Street Address City, State Zip 2. UNIFORMED SERVICES Active duty in the Uniformed Services of the United States includes: Air Force, Army, Navy, Marine Corps, Was a parent/guardian on Coast Guard, NOAA Corps, Air Force, Public Health Service Commissioned Corps and Accredited Foreign ACTIVE duty on December 1, Military. This applies to members stationed anywhere in the world. 2020? If YES, please provide the following information YES Name of ACTIVE DUTY parent/guardian: ______________________________________________ If a reservist was called to active duty, please provide a copy of Branch of Service: orders. □ Army □ Navy □ Marines □ Coast Guard □ NOAA □ Air Force □ ____________________________ NO Rank: (i.e., E-1, O-1, etc.) 3. CIVILIANS EMPLOYED If YES, please provide the following information ON FEDERAL PROPERTY Name of CIVILIAN parent/guardian: __________________________________________________ Name of EMPLOYER who you work FOR: (Required) Example: I work FOR the: DOD, IMF, DON, Was a parent/guardian etc. ____________________________________________________________________________ employed on or reporting to Name of federal property you work ON (check one or write in space provided) work on federal property on □ Army Reserve Center, 5119 E Portland Ave – E 52nd, Tacoma, WA 98422 December 1, 2020? □ Camp Murray, Bldg 1 Camp Murray, Tacoma, WA 98430 YES → □ Coast Guard Support Center, 27th Ave W & Commodore WA, Seattle, WA 98134 If yes, please provide □ Emerald Queen Casino/Puyallup reservation, 2024 E 29th St, Tacoma, WA 98424 parent/guardian name and □ FAA Air Route Traffic Control Center, 3101 Auburn Way S, Auburn, WA 98002 name of employer and federal □ Federal Center South, 4735 E Marginal Way/915 2nd Ave, Seattle, WA 98110 property. □ Federal Detention Center- Sea Tac, 2425 S 200th St, Seattle, WA 98110 NO □ Federal Office Bldg, 1st Ave – 2nd Ave – Madison & Marion Sts, Seattle, WA 98110 This information is the basis for □ Joint Base Lewis-McChord, 2140 Liggett Ave, JBLM Tacoma, WA 98443 payment to your school district □ Little Creek Casino Resort, 91 WA-108, Shelton, WA 98584 of federal funds under the □ Merchant Marine (homeport of ship on December 1, 2019): _____________________________ Impact Aid Program (Title VIII of - Ship’s Name and Hull Number: _____________________________________________________ the Elementary and Secondary □ Muckleshoot Casino Resort, 2402 Auburn Way S, Auburn, WA 98002 Education Act) and may be □ Naval Air Station, Whidbey Island, 3675 Lexington Rd, Oak Harbor, WA 98278 provided to the U.S. □ Naval Base Kitsap, 1100 Hunley Rd, Bangor, WA 98315 Department of Education if your □ Naval Hospital Regional Medical Center, 1 Boone Rd, Bremerton, WA 98310 school district’s application for □ Naval Jackson Park Housing/Naval Reservation, 100 Olding Rd, Bremerton, WA 98312 payment is audited. This form must be signed and dated for □ Naval Reserve Training Center, 11th & Alexander, Tacoma, WA 98422 your school district to receive □ Naval Station- Puget Sound, 1922 W Marine View Dr, Everett, WA 98201 funds based on this information. □ Naval Strategic Weapons Facility, 6401 Skipjack Circle, Silverdale, WA 98383 □ Naval Supply Center, 467 West Dr, Bremerton, WA 98310 □ Naval Supply Depot- Fuel Branch, Hilldale Rd, Manchester, WA 98353 □ Nisqually Indian Tribe, 4820 She-Nah-Num Dr SE, Olympia, WA 98513 □ Nisqually Red Wind Casino, 12819 Yelm Hwy SE, Olympia, WA 98513 □ Puget Sound Naval Shipyard (PSNS)/Naval Base Kitsap, 1400 Farragut, Bremerton, WA 98310 □ US Courthouse & Federal Building, 700 Stewart St, Seattle, WA 98110 □ VA Hospital, 1660 S Columbia Way, Seattle, WA 98110 □ VA Hospital Fort Lewis-Lakewood-Tacoma-American Lake, 9600 Veterans Dr, Tacoma WA 98493 □ Other federal property:_______________________Address_____________________________ By signing this form, I am certifying that all typed and written information on this form is accurate and complete as of the survey date, December 1, 2020. ______________________________________________________________ _______________ Signature of Parent/Guardian Date .

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