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Code No. 503.3E1 Student Fee Waiver Application

Standard Fee Waiver Application

 

Date____________________                                                 School Year______________

 

All information provided in connection with this application will be kept confidential.

 

Name of Student: ___________________________ Grade in school___________

Name of Student:___________________________ Grade in school___________

Name of Student:___________________________ Grade in school___________

 

Attendance Center/School:__________________________________________________

 

Name of parent, guardian: or legal or actual custodian:____________________________

 

Please check type of waiver desired:

 

          Full waiver________ Partial waiver________ Temporary waiver_______

 

Please check if the student or the student's family meets the financial eligibility criteria or is involved in one of the following programs:

 

Full Waiver:

 

            _________ Free meals offered under the Child Nutrition Program

            _________ The Family Investment Program (FIP)

            _________ Supplemental Security Income (SSI)

            _________ Transportation assistance under open enrollment

            _________ Foster care

 

Partial waiver

 

            _________ Reduced priced meals offered under the Child Nutrition Program

Temporary Waiver

If none of the above apply, but you wish to apply for a temporary waiver of school fees because of serious financial problems, please state the reason for the request:

_________________________________________________________________________________________________________

 

Signature of parent, guardian or legal or actual custodian:____________________________________________________

Note:  Your signature is required for the release of information regarding the student or the student's family financial eligibility for the purpose checked above.

Revised/Reviewed:   April 22, 2024