504.12E1 Student Fee Waiver Application

All information provided in connection with this application will be kept confidential.

Name of parent/guardian:_________________________________________________

Date______________________ School year______________

Name of student:______________________________ Grade in school:____________

Name of student:______________________________ Grade in school:____________

Name of student:______________________________ Grade in school:____________

Name of student:______________________________ Grade in school:____________

Please check the type of waiver desired:

Full waiver_____ Partial waiver_____ Temporary waiver_____

Please check if the student or the student's family meet the financial eligibility criteria or is involved in one of the following programs:

Full Waiver:

_____ Free meals offered under the Children 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 or actual custodian

(Your signature is required for the release of information regarding the student or the student's family financial eligibility for the program checked above.)

Please return this completed form to the principal's office.

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