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/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 Child Nutrition Program

            _____ 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/actual custodian:  ___________________________________

 

 

Approved    4/11/05                        
Reviewed   11/15/21                                                                      
Revised