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 / Actual Custodian)
Please check type of waiver desired:
Full Wavier 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 / Actual Custodian)
Approved: August 1996
Reviewed: February 2017, May 2020
Revised: May 2009
