503.3E1 STANDARD FEE WAIVER APPLICATION

Date

School year

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

Name of student:

Grade in school

Name of student:

Grade in school

Name of student:

Grade in school

Attendance Center/School:

Name of parent, guardian:

  or legal or 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 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