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 wavier 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 (CNP)
_________ 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
