Code No.  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 (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