504.1E1 - 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 Children Nutrition Program(CNP)

________ The Family Investment Program (FIP)

________ Transportation assistance under open enrollment

________ Foster Care

 

Partial waiver

________  Reduced priced meals offered under the Children Nutrition Program

 

Temporary waiver                                                                                                                                                 

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

 

Signature of parent, guardian, or legal of actual custodian________________________________