SIGN UP FOR LOTTERY NOW!

Transcription

1 SIGN UP FOR LOTTERY NOW! UNIVERSAL PRE-KINDERGARTEN APPROVED FOR KERHONKSON NY If you have a youngster who will be 4 years old by 12/1/16 and you are a resident of the Kerhonkson Elementary School, they are eligible to participate in the Full Day Universal Pre Kindergarten (UPK) program. We offer a free full day preschool experience 5 days a week at the Kerhonkson Elementary School. Busing will be provided at designated pickup points. Applications are available at: The Kerhonkson Elementary School or go to the Rondout website and click on the Kerhonkson School Home page. Lottery will be 5/4/16 at the District Office Openings are limited!* *Family considered economically disadvantaged have priority per grant requirements. Any questions please call Louann x4863.

2 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT P.O. Box 9 Accord, New York Mr. Rosario Agostaro Dr. Timothy Wade Superintendent of Schools Deputy Superintendent Ext Ext Mrs. Lisa Pacht Mrs. Debra Kosinski Executive Director of Curriculum & Instruction School Business Administrator Ext Ext Dear Parent/Guardian, SPRING 2016 Full Day Program at Kerhonkson Elementary School Attached you will find a lottery application for anticipated Universal Pre-Kindergarten seats for the academic year. Seats will be offered based on a public lottery to be held on May 4, 2016 at 4:00 p.m. at the District Office. You must be a resident of the Kerhonkson Elementary School in the Rondout School District Your child must be 4 years old on/before December 1, Complete all enclosed Forms. Return all forms to the Rondout Valley Central School District Office by 4:00 p.m. on May 2, Please review the enclosed information carefully. All required documents (see page 2) must be received no later than July 1, 2016 in order for your child to attend school in September. (We must have a Physical form and Updated Immunizations before they can attend UPK) You may bring your required documents to the District Office and we will copy them for you, or they may be faxed to: Atten: UPKFDK or mailed to: Rondout Valley CSD DO-PPS-UPKFDK PO Box 9 Accord, NY All are welcome to attend the lottery on May 4 th and May 17 th although your presence is not required. Full Day lottery is May 4, 2016 at 4:00 p.m. at the District Office. ½ Day Pre-Kindergarten Lottery will take place on May 17, 2016 at 6:00 p.m. in the Intermediate School Lecture Hall. Robin Doick CSE/CPSE Chairperson Pupil Personnel Services Ext. 4863

3 Please keep this page for your information Due to NYS Immunization requirements we must ask for documentation. All Preschoolers must be up to date on immunizations and Well Child exam before attending school. *PLEASE NOTE: DOCUMENTS REQUIRED BY JULY 1st 1)Proof of Residency- copy of bill/receipt with name and physical address 2)Copy of Birth Certificate 3)Copy of Shot Records 4)Copy of Physical Exam -physical must be done between 9/15-9/16 (please take enclosed Health Assessment Form to your Doctor) NY State Immunization Requirements for School Entrance/Attendance Vaccines Diphtheria and Tetanus Toxoid-Containing Vaccine and Pertussis Vaccine (DTaP/ DTP/Tdap) Pre-kindergarten (Day Care, Nursery, Head Start, or Pre-K) Kindergarten 4 doses 4-5 doses (See footnote 2b) Polio (IVP or OPV) 3 doses 3-5 doses (See footnote 4a-c) Measles, Mumps and Rubella(MMR) 1 dose (See footnote 5ab) 2 dose Hepatitis B 3 doses (See footnote 6a) 3 doses Varicella(Chickenpox) 1 dose (See footnote 7ab) 2 doses Haemophilus influenzae type b conjugated 1-4 doses (See footnote 8a-d) Not applicable vaccine (Hib) Pneumococcal Conjugate Vaccine (PCV) 1-4 doses (See footnote 9a-d) Not applicable 4. Inactivated poliovirus vaccine IPV (Minimum age: 6 weeks) 4a. Children starting the series on time should receive a series of IPV at ages 2,4,6 through 18 months and 4 years of age or older. The final dose in the series must be received on or after the fourth birthday and at least 6 months after the previous dose. 4c. If the third dose of polio vaccine was received at age 4 years or older and at least 6 months after the previous dose, the fourth dose of polio vaccine is not necessary. 5. Measles, Mumps and Rubella (MMR) vaccine (Minimum age: 12 months) a. The first dose of MMR vaccine must have been received on or after the first birthday. The second dose must have been received at least 28 days(4 weeks) after the first dose to be considered valid. b. One dose of MMR is required for prekindergarten. 6. Hepatitis B Vaccine a. Dose 1 may be given at birth or anytime thereafter. Dose 2 must be received at least 4 weeks (28 days) after dose 1. Dose 3 must be at least 8 weeks after dose 2 AND at least 16 weeks after dose 1 AND no earlier than 24 weeks of age. 7. Varicella (chickenpox) vaccine (Minimum age: 12 months) 7a.The first dose of varicella vaccine must have been received on or after the first birthday. The second dose must have been received at least 28 days (4 weeks) after the first dose to be considered valid. b. One dose is required for prekindergarten. 8. Haemophilus influenza type b (HIB) (minimum age: 6 weeks) 8a.Children starting the series on time should receive Hib vaccine at 2, 4, 6 months and months of age. b. If 2 doses of vaccine were received before 12 months of age, only 3 doses are required with dose 3 at 12 through 15 months of age and at least 8 weeks after dose 2. c. If dose 1 was received at ages months of age, only 2 doses are required with dose 2 at least 8 weeks after dose 1. d. If dose 1 was received at 15 months of age or older, only 1 dose is required. 9. Pneumococcal conjugate vaccine (PCV) (Minimum age: 6 weeks) a. Children starting the series on time should receive PCV vaccine at 2, 4, 6 months and months of age. Final dose must be received at months of age. b. Unvaccinated children 7 11 months of age are required to receive 2 doses, at least 4 weeks apart, followed by a third dose at age months. c. Unvaccinated children months of age are required to receive 2 doses of vaccine at least 8 weeks apart. d. If one dose of vaccine was received at 24 months of age or older, no further doses are required.

4 Fax Physical & Immunizations to: Mail to: Rondout Valley CSD-PPS-UPK PO Box 9 Accord, NY RONDOUT VALLEY CENTRAL SCHOOL DISTRICT HEALTH SERVICES P.O. BOX 9, ACCORD, N.Y NYSED requires an annual physical exam for UPK, new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and triennially for the Committee on Special Education (CSE) HEALTH ASSESSMENT FORM Name: Date of Birth: School: Gender: M F Grade: IMMUNIZATIONS/ HEALTH HISTORY Immunization on record attached Sickle Cell Screen: Positive Negative Not Done Date: No immunizations given today PPD: Positive Negative Not Done Date: Immunizations given since last Health Appraisal: Elevated Lead: Yes No Not Done Date: Dental Referral Yes No Not Done Date: Significant Medical/Surgical History: see attached Specify current diseases: Asthma Diabetes: Type 1 Type 2 Hyperlipidemia Hypertension Other: Allergies: LIFE THREATENING Food: Insect: Other: Seasonal Medication: PHYSICAL EXAMS Height: Weight: Blood Pressure: Date of Exam: Body Mass Index: - Weight Status Category (BMI Percentile): Less than 5 th 5 th through 49 th 50 th through 84 th 85 th through 94 th 95 th through 98 th 99 th and higher Vision - without glasses/contact lenses R L Vision with glasses/ contact lenses R L Vision Near Point R L Hearing Pass 20 db sc both ears or: R L EXAM ENTIRELY NORMAL Tanner: l. ll. IIl. lv. V. Scoliosis: Negative Positive: Specify any abnormality (use reverse of form if needed): MEDICATIONS Medications (list all): None Additional medications listed on physician letter head stationary Name: Dosage/ Time: Name: Dosage/Time: If AM dose is missed at home: I assess this student to be self directed Yes No Student may self carry and self administer medication Yes No Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if morning medication has not been given. PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked: Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball. Non-contact: badminton, bowl, golf, swim, table tennis, archery, riflery, weight train, crew, dance, track, run, walk, rope jump. Specify medical accommodations needed for school: Known or suspected disability: Restrictions: None Please monitor Please monitor Protective equipment required: Athletic Cup Support goggles/impact resistant eyewear Other: Provider s Signature: Phone: Provider s Name/ address: Fax: Parent Signature: Date: This exam complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more that five days that will require review by private healthcare and the school medical director. DH #6new 1/08

5 Full Day Pre Kindergarten Lottery Application Rondout Valley Central School District Office of Pupil Personnel P.O. Box 9 Accord, New York Name of Student: Male/Female (Please Circle one ) Date of Birth: Must be 4 years old on December 1, 2016 Father/Legal Guardian: Cell#: Mother/Legal Guardian: Cell#: Mailing Address: Home Phone #: After the Full Day Lottery: If my child is on the waiting list for Full Day Universal Prek at Kerhonkson Elementary School I would like to: Keep my child on waiting list for Full Day program Include my child in the lottery for ½ day Universal Prek My choices are: We have 4 schools participating in our ½ Day Universal Prekindergarten program: The Brookside School in Cottekill on Lucas Ave. RMCC Preschool at the Rondout Methodist Church on Schoonmaker Lane Ulster County Community College ChildCare Lederman Children s Center on Rt 213 Please indicate below your preference in rank order with: 1- being your first choice 2- second choice 3- third choice 4-Fourth Choice Morning Afternoon Brookside School Afternoon sessions are available Wrap around available* RMC Cooperative PreSchool No afternoon session/wrap around available** UCC Childcare Center No afternoon session/wrap around available* Lederman Children s Center No afternoon session/wrap around available* *Wrap around-parent pays for afternoon session **Check with Martha for availability-parent pays for afternoon session This Lottery Application and all enclosed Forms must be delivered to the Office of Pupil Personnel at the Rondout Valley Central School District Office by 4:00 p.m., May 2, ) Full Day lottery is May 4, 2016 at 4:00 p.m. at the District Office. 2) ½ Day Pre-Kindergarten Lottery will take place on May 17, 2016 at 6:00 p.m. in the Intermediate School Lecture Hall.

6 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT UPK REGISTRATION FORM-KERHONKSON Student First Name Middle Name Student Last Name Physical Address (Street Address) (City) (State) (Zip) Mailing Address (if different) (PO Box/address) (City) (State) (Zip) Town/Village of Residence Address: Mother Father (Please circle one) Father/Legal Guardian s Name: Mother/Legal Guardian s Name: Student s Sex M F Student s Place of Birth Student s Date of Birth: Special Programs/IEP: Date of Entry (if not born in US) Country of Origin (City) (State) (Zip) Number of years in US Schools: What languages does the student understand? Home Language What language does student: Read Write Race (circle one) Hispanic Non-Hispanic International Adoption? YES NO Date of Adoption Ethnicity (circle one): I American Indian or Native America A Asian B- Black or African American H Hispanic or Latino P Native American or other Pacific Islander W - White RESIDENCY INFORMATION ( please circle one) Student lives with: Both Parents Father Mother Legal Guardian Stepparent Relative Relationship: Foster Home PLEASE NOTE PLACEMENT AGENCY & ADDRESS: Date of 1 st Polio Immunization: STUDENT LIVING ARRANGEMENTS Is the student homeless?.. Is the student living in a shelter: Is the student living with relatives due to lack of housing?... Is the student living in an abandoned apartment/building?... Is the student living in a motel/hotel?... Is the student living in a campground, car, train/bus station or other similar situation due to lack of alternative, adequate housing?... Is the student temporarily housed in a shelter awaiting OCF S permanent foster care placement?... YES YES YES YES YES YES YES NO NO NO NO NO NO NO

7 TELEPHONE NUMBERS (Fill out employer information only for parent(s), Legal Guardian or Relative that student lives with) HOME# WORK# CELL# Father Father s Employer Mother Mother s Employer Guardian Guardian s Employer Relative Relative s Employer Name ****EMERGENCY NUMBERS**** Relationship Address Permission to pick up student: YES NO Phone # Cell # OTHER CHILDREN Sex Date of Birth Attending Rondout? Brother s Names Yes No Sister s Names

8 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT TRANSPORTATION FORM FOR KERHONKSON UPK FULL DAY ONLY Student ID# (For office use) Family ID# (For office use) Student s Name Sex: M F Grade: Date of Birth Please circle one: Student Lives with: Both Parents Father Mother Guardian Relative Parent s Name Guardian / Relative Name Physical address: City State Zip Code Mailing address (if different from physical address) City State Zip Code Father Mother Guardian / Relative Home Phone Number: Work Phone Number: Cell Phone Number: Phone number to be contacted in case of emergency: Name: Relationship to student: Phone number:

9 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT HEALTH SERVICES HEALTH/ EMERGENCY INFORMATION Bus Route No.: // ID#: Grade in Sept.: Year: 16/17 Homeroom Teacher Student Name: Date Of Birth: M F (Last) (First) (Middle) Residence Address: Is this address new? Y (Location of Home: Street/Road/Fire No.) N Mailing Address: Is this address new? Y N (PO Box or No. of Street or Road) Student resides with (circle one): Both Parents at same address Both Parents at separate addresses Mother Father Mother/Stepfather* Father/Stepmother* Guardian* Foster Parents* Grandparents* Parent/Guardian Name: Relationship to Child: Residence Address: Mailing Address: Home Phone: Business Phone: Cell Phone: e mail address: Parent/Guardian Name: Relationship to child: Residence Address: Mailing Address: Home Phone: Business Phone: Cell Phone: e mail address: Are there any custody issues with court papers given to school office? YES or NO (circle if applicable) *Name of natural Parent/Guardian not living in the home (include address & phone if available). Contact in emergency? YES or NO * Name & Mailing Address of Guardian, Grandparent, Step Parent or Foster Parent if not included above (include residence address if different): *Home Phone, Business, or Cell of Guardian, Grandparent, Step Parent, or Foster Parent: List two local relatives or neighbors to contact if you are not available: (I give permission for these people to pick up my child and assume temporary care if necessary and I cannot be reached) 1) (Name) (Address) (Phone) 2) (Name) (Address) (Phone) List other brothers/sisters currently attending Rondout Valley Central Schools: (Name) (DOB) (School building name) (Grade in Sept.) (List address if different than above) (Name) (DOB) (School building name) (Grade in Sept.) (List address if different than above) (Name) (DOB) (School building name) (Grade in Sept.) (List address if different than above) (Name) (DOB) (School building name) (Grade in Sept.) (List address if different than above)

10 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT HEALTH OFFICE EMERGENCY FORM Hospital Choice: Doctor: 1 st Choice Phone: 2 nd Choice Phone: Hospitalization coverage name of insurance company contract policy # In the event that neither parent/guardian can be contacted in a serious emergency requiring medical attention, you have my permission to take my child to the Emergency Room and this note will serve as authorization for the Emergency Room Staff to take whatever steps they think necessary for the welfare of my child. Signature of Parent/Guardian Date Dear Parent/Guardian: Every year it is necessary to update the health information on your child. Please indicate below any pertinent information regarding your child s health that we should be aware of during the time she/he is in school. Also, indicate the course of action you would like followed if a problem occurs. It is your right to approve or disapprove the sharing of this information with the appropriate staff. Though we feel that it is important for the appropriate staff to have this information in order to better understand any problems that may arise during the school day, it will only be shared with them if you approve. Sincerely, School Nurse HEALTH INFORMATION AND INSTRUCTIONS: I give my permission to have this health information shared with all appropriate staff. I realize that this information will be available to the School Nurse and Principal, but I do not want this shared with any other staff. Signature of Parent/Guardian Date DH #2a 06/14

11 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT PO BOX 9 ACCORD, NY STUDENT ADMISSION HEALTH HISTORY Student s Name: Sex: M F Date of Birth: Place of Birth: Address: Phone Number: Previous School Name and Address: Previous Grade and Teacher: Entry Date: Individual providing health history: Parent: Address Phone: Parent: Address Phone: Guardian: Address Phone: Health History: Were there any issues during pregnancy, labor and/or delivery for this child? If yes, please describe: Yes No Birth Weight Does this child have an ongoing health concern? (asthma, diabetes, etc.) If yes, please describe: Does this child have any allergies? Yes No If yes, please list: Has the allergy required emergency treatment? Yes No If yes, please explain: Is there a history of any hospitalizations, accidents, significant injuries or surgery? If yes, please describe: Yes No Yes No Are there any current medical concerns/injuries? Yes No Head Eyes Nose Ears Throat Neck Chest Respiratory Cardiovascular Gastrointestinal Genitourinary Neurological Musculoskeletal (include any past fractures, etc.) Does this child take any medication regularly at home? Require medication at school? If yes, please describe: Yes No Yes No Has this child been examined by any of the following (please give date): Pediatrician Psychiatrist Ophthalmologist Psychologist Optometrist Speech Clinic Neurologist Physical/Occupational Therapist Other

12 Describe your child s nutrition pattern and dietary intake: Developmental milestones: At what age did your child: Sit alone: Crawl: Walk alone: Talk (two words together): Achieve daytime toilet training: Is bedwetting a problem: Yes No If so, please explain: Family Health History: List any significant medical concerns in family: Parent Parent Siblings Grandparents Other Family and Social History: Parents (Please list names and birth year): Siblings: Have there been any difficult times in the child s life that you think may help us understand him/her? Tell us about your child s personality: Who lives with the child in his/her primary household? Does child spend a significant amount of time in another household? Yes No If yes, please describe: Who has legal custody of this child? Describe any custody arrangements: Please list any additional concerns or information: Signature of Parent/Guardian: DH#2 03/13 Date:

13 RONDOUT VALLEY CENTRAL SCHOOL PO Box 9 Accord, NY Fax RESIDENCE VERIFICATION I hereby certify that: resides with me at (Students Name) (Street Address & Town) is a bonafide resident of (Students Name) the Rondout Valley Central School District as evidenced by the fact he/she lives at the residence on a permanent basis. has no other residence (Student Name) or domicile** and my relationship to (Student Name) is (Relationship to Student) (Signature) (Date) * A permanent basis means that this child sleeps at your residence during the week and on weekends, and spends vacations and holidays at your residence. This takes into consideration that there are times a child can be away from home for vacations, to visit relatives, or to sleep over at a friend s house. **A domicile is a place, which an individual considers his permanent home

14 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT P.O. Box 9 Accord, New York Mr. Rosario Agostaro Dr. Timothy Wade Superintendent of Schools Deputy Superintendent Ext Ext Mrs. Lisa Pacht Mrs. Debra Kosinski Executive Director for Curriculum & Instruction School Business Administrator Ext Ext PARENTAL PERMISSION FOR USE OF STUDENT NAMES, PHOTOGRAPHS & VIDEO Dear Parent/Guardian, The Rondout Valley Central School District is changing its practice of publishing student names, photographs and videos. From here forward, the district will publish names, photographs and videos of students unless parents/guardians have completed and returned the following form expressing that they do not give consent to publish his or her child s name, photograph or video. Student names, photographs and videos will be used only for educational and/or public relations purposes, in newsletters, on the district website, etc. and student names will not be used together with their photo or video. OPT OUT FORM I,, the parent/legal guardian of student (Please print parent/guardian s name), DO NOT give my permission to the Rondout Valley (Please print student s name) Central School District to use my child s name, photograph or video. Full Parent/Guardian Signature Date /rc upk kes

15 RONDOUT VALLEY CENTRAL SCHOOL DISTRICT P.O. Box 9 Accord, New York Mr. Rosario Agostaro Dr. Timothy Wade Superintendent of Schools Deputy Superintendent Ext Ext Mrs. Lisa Pacht Mrs. Debra Kosinski Executive Director for Curriculum & Instruction School Business Administrator Ext Ext Dear Pre-Kindergarten Parent/Guardian, We have the capability of sending phone calls, s, and/or text messages to inform you of school delays, emergency closings, and upcoming events in the district. This is accomplished through an automated system which we use to contact parents, students, and staff. If you would like the district to register you for this service, please fill in this form and return it with your Universal Pre-Kindergarten application. Parent/Guardian Name Student Name I would like the Rondout Valley Central School District to send me notifications about: Emergency Closings/Delays Upcoming Community Events Please check all that apply below regarding how you would like to receive the reminders. I prefer to receive notifications through a(n): Phone E Text Should you have any questions, please contact Ms. Randi Chase in the Technology Office at the following phone number: extension Thank you, Superintendent Rosario Agostaro upk kes

16 Date Withdrew Attachment Va F R D Application for Free and Reduced Price School Meals/Milk To apply for free and reduced price meals for your children, read the instructions on the back, complete only one form for your household, sign your name and return it to Rondout Valley CSD Food Services Dept. Call (845) X 4233, if you need help. Additional names may be listed on a separate paper. 1. List all children in your household who attend school: Student Name School Grade/Teacher Foster Child Homeless Migrant, Runaway 2. SNAP/TANF/FDPIR Benefits: If anyone in your household receives either SNAP, TANF or FDPIR benefits, list their name and CASE # here. Skip to Part 4, and sign the application. Name: CASE # 3. Report all income for ALL Household Members (Skip this step if you answered yes to step 2) A. Child Income Sometimes children in the household earn income. Please include TOTAL income earned by all Household Members listed in step 1 here. $ How often? Weekly Bi-Weekly 2X Month Monthly B. All Adult Household Members (including yourself) List all Household members not listed in Step 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total income for each source in whole dollars only. If they do not receive income from any other source, write 0. If you enter 0 or leave any fields blank, you are certifying (promising) that there is no income to report. Name of household member Earnings from work before deductions Amount / How Often Child Support, Alimony Amount / How Often Pensions, Retirement Payments Amount / How Often Other Income, Social Security Amount / How Often No Income $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / $ / Total Household Members (Children and Adults) 4. Signature: An adult household member must sign this application and provide the last four digits of their Social Security Number (SS#), or mark the I do not have a SS# box before it can be approved. I certify (promise) that all of the information on this application is true and that all income is reported. I understand that the information is being given so the school will get federal funds; the school officials may verify the information and if I purposely give false information, I may be prosecuted under applicable State and federal laws, and my children may lose meal benefits. Signature: Date: Address: Last Four Digits of Social Security Number: XXX-XX- Home Phone: Work Phone: Home Address: DO NOT WRITE BELOW THIS LINE FOR SCHOOL USE ONLY Annual Income Conversion (Only convert when multiple income frequencies are reported on application) Weekly X 52; Every Two Weeks (bi-weekly) X 26; Twice Per Month X 24; Monthly X 12 SNAP/TANF/Foster Income Household: Total Household Income/How Often: / Household Size: Free Meals Reduced Price Meals Denied/Paid Signature of Reviewing Official Date Notice Sent: I do not have a SS#

17 APPLICATION INSTRUCTIONS To apply for free and reduced price meals, submit a Free Meals/Milk Eligibility Letter received from the Office of Temporary and Disability Assistance OR complete only one application for your household using the instructions.. Sign the application and return the application to. If you have a foster child in your household, you may include them on your application. A separate application is no longer needed. Call the school if you need help:. Ensure that all information is provided. Failure to do so may result in denial of benefits for your child or unnecessary delay in approving your application. PART 1 ALL HOUSEHOLDS MUST COMPLETE STUDENT INFORMATION. DO NOT FILL OUT MORE THAN ONE APPLICATION FOR YOUR HOUSEHOLD. (1) Print the names of the children, including foster children, for whom you are applying on one application. (2) List their grade and school. (3) Check the box to indicate a foster child living in your household, or if you believe any child meets the description for homeless, migrant, runaway (a school staff will confirm this eligibility). PART 2 HOUSEHOLDS GETTING FOOD STAMPS, TANF OR FDPIR SHOULD COMPLETE PART 2 AND SIGN PART 4. (1) List a current Food Stamp, TANF or FDPIR (Food Distribution Program on Indian Reservations) case number of anyone living in your household. Do not use the 16-digit number on your benefit card. The case number is provided on your benefit letter. (2) An adult household member must sign the application in PART 4. SKIP PART 3. Do not list names of household members or income if you list a food stamp case number, TANF or FDPIR number. PART 3 ALL OTHER HOUSEHOLDS MUST COMPLETE THESE PARTS AND ALL OF PART 4. (1) Write the names of everyone in your household, whether or not they get income. Include yourself, the children you are applying for, all other children, your spouse, grandparents, and other related and unrelated people in your household. Use another piece of paper if you need more space. (2) Write the amount of current income each household member receives, before taxes or anything else is taken out, and indicate where it came from, such as earnings, welfare, pensions and other income. If the current income was more or less than usual, write that person s usual income. Specify how often this income amount is received: weekly, every other week (bi-weekly), 2 x per month, monthly. If no income, check the box. The value of any child care provided or arranged, or any amount received as payment for such child care or reimbursement for costs incurred for such care under the Child Care and Development Block Grant, TANF and At Risk Child Care Programs should not be considered as income for this program. (3) The application must include the last four digits only of the social security number of the adult who signs PART 4 if Part 3 is completed. If the adult does not have a social security number, check the box. If you listed a food stamp, TANF or FDPIR number, a social security number is not needed. OTHER BENEFITS: Your child may be eligible for benefits such as Medicaid or Children s Health Insurance Program (CHIP). In order to determine if your child is eligible, program officials need information from your free and reduced price meal application. Your written consent is required before any information may be released. Please refer to the attached parent Disclosure Letter and Consent Statement for information about other benefits. PRIVACY ACT STATEMENT Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number are not required when you apply on behalf of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. DISCRIMINATION COMPLAINTS The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (PDF), found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities and you wish to file either an EEO or program complaint please contact USDA through the Federal Relay Service at (800) or (800) (in Spanish). USDA is an equal opportunity employer.