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________________________________
