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 or actual custodian
Please check type of waiver desired:
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
Partial waiver
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 or actual custodian
Note: Your signature is required for the release of information regarding the student or the student's family financial eligibility for the programs checked above.
UPLOAD FORM