Date_____________________________ School year_____________
Name of student(s):____________________________ Grade in school __________
____________________________ __________
____________________________ __________
____________________________ __________
____________________________ __________
To be eligible for FULL WAIVER, you or your child must meet one or more of the following guidelines:
Free meals offered under the Child Nutrition Program
The Family Investment Program (FIP)
Supplemental Security Income (SSI)
Transportation assistance under open enrollment
Foster Child
To be eligible for PARTIAL WAIVER, you must meet the following criteria:
Reduced –priced meals offered under the Child Nutrition Program
Please circle the type of waiver that you believe you are eligible to receive:
Full Waiver Partial Waiver
If you child(ren) qualifies for free or reduced price meals, you may also be eligible for other benefits. Some of these benefits are Book Rent, Computer Rent, Accounting
I and II, Vocal Text Fee/Sr. High, Cleaning Fee/Band/Sr. high, Music Text Fee 5-8, Driver Education and CPR 9th grade. If you sign this waiver, your child(ren) will be
considered for a full or partial waiver of Book rent, Computer Rent, Accounting I and II, Vocal/Text Fee/Sr. high, Cleaning Fee Band High, Music Text Fee 5-8, Driver’s
Education and CPR 9th grade. I understand that I will be releasing information that will show that I applied for free and reduced price school meals for my child(ren). I
give up my rights to confidentiality for waiver of school fees ONLY.
I certify that I am the parent/guardian of the child(ren) for whom application is being made.
Signature of parent, guardian:_____________________________________________________________
or legal or actual custodian
YOU DO NOT HAVE TO COMPLETE THIS WAIVER TO GET FREE OR REDUCED PRICE SCHOOL MEALS, BUT DO NEED TO COMPLETE IN ORDER
TO RECEIVE FREE OR REDUCED PRICE ON SCHOOL FEES.
NOTE: Your signature is required for the release of information regarding the student or this student's family financial eligibility for the program checked above.
