503.3E1 Standard Fee Waiver Application

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: ________ School: _______________

Name of student: ___________________________Grade: ________ School: _______________

Name of student: ___________________________Grade: ________ School: _______________

Name of student: ___________________________Grade: ________ School: _______________

Name of student: ___________________________Grade: ________ School: _______________

 

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)  ______________________________________    

Date ___________________

Determining Official ___________________________________   Date ___________________

 

Approved:10/28/09

Reviewed: 2/24/16

Revised: 2/6/22

Grinnell-Newburg School District, Grinnell, IA