Code No. 501.13R1
Exhibit A
STUDENT 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 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 Child Nutrition Program
________The Family Investment Program (FIP)
________Transportation assistance under open enrollment
________Foster care
Partial waiver
________Reduced price meals offered under the Child Nutrition Program
Signature parent, guardian, or legal or actual custodian:________________________________________
Note: Your signature is required for the release of information regarding the student's or the student's family financial eligibility for the programs checked above.
Date of Last Review: October 14, 2019
Form Revised: March 10, 2008
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DECORAH COMMUNITY SCHOOL BOARD OF DIRECTORS