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 (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 fees because of serious financial problems, please state the reason for the request:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Signature of parent, guardian:  _______________________________________________________________________________
  or legal or actual custodian