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:
____________________________________________________________________________________________
___________________________________________________________________________________________________
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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