Date: ________________ School Year: ________________________
All information provided in connection with this application will be kept confidential.
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: ___________________________________
