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 Children 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 Children 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 programs checked above.

Reviewed: 3/11/24