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
