If your child(ren) qualifies for free or reduced price meals, you may also be eligible for other benefits. One of these benefits is school fees.  If you sign this waiver, your child(ren) will be considered for a full or partial waiver of school fees.  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 the application is being made.

 

Signature of Parent/Guardian __________________________________________            Date _________________

 

 ________ Approved         _________ Denied           _________________________Date _________________

                                                                                                        (school official) 

 

YOU DO NOT HAVE TO COMPLETE THIS WAIVER TO GET FREE OR REDUCED PRICE SCHOOL MEALS.

 

 Name of Student ___________________________________                      Grade in School _________________     

Name of Student ___________________________________                      Grade in School _________________

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 type of waiver desired:      

____________ Full Waiver         _________ Partial Waiver           __________ Temporary Waiver

 

Please check if 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)

________          Supplemental Security Income (SSI)

________          Foster Care

 

Partial Waiver

________          Reduced Price Meals offered under the Child Nutrition Program

 

Temporary Waiver

________          If none of the above apply, but you wish to apply for temporary waiver of school fees because of serious financial problems, please state the reason for the request:____________________________________________________________________________________

________________________________________________________________________________________________________     

 

Approved  9/23/11     Reviewed   8/18/2021             Revised