Date: School Year:
All information provided in connection with this application will be kept confidential
Name of Student: Grade:
Name of Student: Grade:
Name of Student: Grade:
Attendance Center/School:
Name of Parent/Guardian:
Please circle type of waiver desired:
Full Partial Temporary
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: ______________________________________
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Signature of Parent/Guardian:
