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
