I, __________________________, hereby request ⬜Full, ⬜Partial, ⬜Temporary) Textbook Fee Waiver for the following student(s):
Child’s Name Registered Concurrent Enrollment Courses
___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
Please list names and ages of all household members:
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Food Stamp Case Number:______________________________________________________
Total Household Monthly Income:_________________________________________________ Address:____________________________________City:_____________________________
Telephone Number:___________________________ Date: ____________________________
Signature of Parent/Guardian:_________________________ Date:_______________________
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For Office Use Only Date submitted: ⬜ Approved, ⬜Denied:
Reason: _______________________________________________________________________________
Approved: 6/12/17 Reviewed: 6/10/19 Revised: