Code No. 503.3E1
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: February 25, 2019