Forward Records to the Appropriate Location Listed Below

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1 Ellsworth Community School District Request for Records Student Name: Date of Birth: Grade in : Name of School last attended: Contact information of school last attended: Phone: Fax: Parent Signature Date: The information to be disclosed and exchanged includes: Official student academic/administrative records (identifying information, grade level completed, grades, class rank, attendance, aptitude and achievement test results) Medical and / or related health records. Psychological evaluations or social worker reports. Appropriate agency reports. Individualized and team reports related to Special Education Other: Forward Records to the Appropriate Location Listed Below Lindgren Early Learning Center N3470 U.S. Highway 63 4YK & Early Childhood Hager City, Wisconsin Phone Fax: Enrollment Contact: Sharon Peterson Hillcrest Elementary 350 South Grant Street Grades K-4 Ellsworth, WI Phone: Fax: Enrollment Contact: Traci Maxwell Prairie View Elementary W th Avenue Grades K-4 Hager City, WI Phone: Fax: Enrollment Contact: Barbara Doughty Ellsworth Middle School 312 West Panther Drive Grades 5-8 Ellsworth, WI Phone Fax: Enrollment Contact: Pauline Laughnan Ellsworth High School 323 Hillcrest Street Grades 9-12 Ellsworth, Wisconsin Phone FAX Enrollment Contact: Kris Deiss Special Education Phone: Fax: Enrollment Contact: Sue Andrews Enrollment is conditional until all records have been received and residency has been verified. The Ellsworth Community School District does not discriminate on the basis of sex, race, color, religion, national origin, ancestry, creed, pregnancy, marital or parental status, sexual orientation, or physical, mental, emotional or learning disability.

2 RESIDENCY VERIFICATION REQUIREMENTS Date: Name of Parent/Guardian Name of Student Grade: Address of Student Telephone: Documents are needed to prove residency in the district. Wisconsin State Statute requires that students attend school in their district of residence and that a school district charge tuition for nonresident students. To enroll your student, bring the following residency documents to the appropriate school office. 1. If you rent, a copy of your rental agreement. 2. If you own or are buying a home, a copy of your real estate tax bill; if you recently purchased a home in the Ellsworth Community School District, a copy of the closing statement. If you have any questions about this required information, our processes or the intent of this letter, please contact us at the numbers listed below or the school district office at Ellsworth High School Hillcrest Elementary Mark Stoesz, Principal John Groh, Principal Ellsworth Middle School Prairie View Elementary Paul Uhren, Principal Mary Zimmerman, Principal

3 ELLSWORTH COMMUNITY SCHOOL DISTRICT ENROLLMENT FORM Please return this registration form to the school office your child is attending. TODAY S DATE: Student Information: Last Name First Name Middle Name Gender Birthdate Grade Birth City Birth State Birth Country Birth County Home Telephone School Home Address City State Zip Code Race / Ethnicity Please answer both questions: 1. Is this student Hispanic or Latino? yes, Hispanic or Latino no, not Hispanic or Latino 2. Is this student (choose all that apply): American Indian or Alaska Native Asian White Black or African American Native Hawaiian or other Pacific Islander Is this student requesting bus transportation? Yes No Parent / Guardian Information: Father s Name (First, Middle, and Last) Address: Mailing Address (if different from above): Home Telephone: Work Telephone: Cell Phone: Address: Mother s Name (First, Middle, and Last) Address: Home Telephone: Work Telephone: Cell Phone: Address: Guardian s Name ( First, Middle, and Last) Address: Home Telephone: Work Telephone: Cell Phone: Address: List other family members in the Ellsworth Community School District. Include those in school and those not in schools up to the age of 21. Name Age Birth Date Grade School

4 Emergency Contacts, Additional Primary and Secondary Contacts: Circle the corresponding letter for each contact: P - primary contact (receive copies of report cards, progress reports, etc.) S secondary E emergency P/S/E Name: Relationship: Father/Mother/child care provider, grandparent, etc. Address: Telephone: P/S/E Name: Relationship: Address Telephone: P/S/E Name: Relationship: Address: Telephone: P/S/E Name: Relationship: Address: Telephone: Doctor Name Relationship: Address: Telephone: Lindgren Early Learning Center - Four Year Old Kindergarten Information 1. Enrolled in special education Early Childhood program: Yes or No 2 St. Francis School is a collaborative partner with the Ellsworth School District in offering four year old kindergarten programming. Please check the program your child is registering for: Lindgren Early Learning Center St. Francis School 3. Location of Child Care Provider: Please indicate the address where your child will be picked up / delivered to by district bus transportation. Only one pick up/drop off location is allowed. Elementary, Middle School & High School Information 1. Is your child in special education? yes no 2. Has this student been expelled from another school? yes no 3. Is this student in the process of being expelled? yes no If yes, please explain: For office use only Date Entered School Add to Ellsworth Census Area. Student is from- District name: Date Entered District Withdraw from Ellsworth Census Area. Student is moving to District Name: Date Withdrawn from District Documentation used to verify residency: Date of residency verification Staff Signature Address to send school records to: Transfer within District From School: To School: Date Data entered in WSLS Date of Exit: Date of Enrollment in this School:

5 ELL Program: Home Language Survey PARENT/GUARDIAN HOME LANGUAGE SURVEY Student's Name Grade Relationship of Person Completing Survey o Mother o Father o Guardian o Other Specify Directions: Check the correct response for each of the following quiestions and indicate other languages if appropriate. English 1. What language did the child learn when she/he first began to talk? o o 2. What language does the family speak at home most of the time? o o 3. What language does the parent(s) speak to her/his child most of the time? o o 4. What language does the child speak to her/his parent(s) most of the time? o o 5. What language does the child hear and understand in the home? o o 6. What language does the child speak to her/his brother/sisters? o o 7. What language does the child speak to her/his friends most of the time? o o Other (Other Languages) 8. Can an adult family member or extended family member speak English? o o 9. Can they read English? o o 10. Do the parents/guardians request oral and/or written communication o o from the school to be in English? If no, in what language? Yes No Signature * Signature of Person Completing Survey Date Signed Office Use Only FOR STAFF COMPLETION TO BE COMPLETED FOR ALL NEW STUDENTS ELL File Opened Today's Date ELL Test Date Test oyes ono ELL Evaluator ELL Level Placement

6 Parent Connect Parents can now access their student's grades, attendance, directory information, and school lunch account online. In order to do this, parents need to provide a 6-8 character password by filling out the information below and returning to the Lindgren office or by ing your name, your child s name, and the desired password to The password will be the same for all children with the same primary parent/guardian, even though they may attend different buildings. If you currently have a child attending one of the other schools in the district, you do not need to submit a new password, your current password will work for your 4YK student. The school district will input the password into the JMC system, which will then allow parent access. (Please allow a day or two after your request.) Once your password has been inputted, you will be able to access your child s account by clicking on the Parent Connect link found in the upper right corner of the Ellsworth School District websitewww.ellsworth.k12.wi.us or by clicking on the following link This will be "read-only" access - - if you need changes made (for instance, your telephone number or address), these changes to your school's office or call and office personnel will make the changes. Child s name Parent/Guardian name Address Password (6-8 characters long)

7 HEALTH HISTORY Child s Name: Date of Birth: First Last Middle Family Physician: Address: Phone: Family Dentist: Address: Phone: Has Your Child Had: Any surgeries? (describe and give dates): Serious illness or accident? (describe and give dates): Is your child on any medication now? If yes, what type? Allergies? or Drug sensitivities? Physical defects, (speech, vision, hearing or others) if so, describe: Health problems which worry you? Training problems? (bed wetting, etc.) Attention span - able to sit still or easily distracted? Easily loses temper? if yes, is it easy to control? Describe: Sleeping habits: restless nightmares sleep walking Illnesses: Pneumonia Ear Infections Scarlet Fever Chicken Pox Asthma Seizure Disorders Diabetes Fainting Spells Severe Headaches Skin Conditions Strep Throat Nephritis Other Any other pertinent information you feel the school should be made aware of: I, give my permission to disclose any or all of this Parent/Guardian Signature information to other health professionals or members of the teaching staff for the purpose of determining the health care needs of this student.

8 DEPARTMENT OF HEALTH SERVICES Division of Public Health F-04020L (Rev. 07/12) STUDENT IMMUNIZATION RECORD STATE OF WISCONSIN and (16) Wis. Stats. INSTRUCTIONS TO PARENT: COMPLETE AND RETURN TO SCHOOL WITHIN 30 DAYS AFTER ADMISSION. State law requires all public and private school students to present written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific requirements are available from schools and local health departments. These requirements can be waived only if a properly signed health, religious, or personal conviction waiver is filed with the school. The purpose of this form is to measure compliance with the law and will be used for that reason only. If you have questions on immunizations or how to complete this form, contact your child s school or local health department. PERSONAL DATA PLEASE PRINT Step 1 Student s Name Birthdate (Mo/Day/Yr) Gender School Grade School Year Step 2 Step 3 Step 4 Name of Parent/Guardian/Legal Custodian Address (Street, City, State, Zip) Telephone Number ( ) IMMUNIZATION HISTORY List the MONTH, DAY AND YEAR your child received each of the following immunizations. DO NOT USE A ( ) OR (X) except to answer the question about chickenpox, Tdap or Td. If you do not have an immunization record for this student at home, contact your doctor or public health department to obtain it. TYPE OF VACCINE* DTaP/DTP/DT/Td (Diphtheria, Tetanus, Pertussis) FIRST DOSE Mo/Day/Yr SECOND DOSE Mo/Day/Yr Adolescent booster (Check appropriate box) Tdap Td Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella (Chickenpox) Vaccine Vaccine is required only if your child has not had chickenpox disease. See below: Has your child had Varicella (chickenpox) disease? Check the appropriate box And provide the year if known: YES year (Vaccine not required) NO or Unsure (Vaccine required) THIRD DOSE Mo/Day/Yr FOURTH DOSE Mo/Day/Yr REQUIREMENTS Refer to the age/grade level requirements for the current school year to determine if this student meets the requirements. COMPLIANCE DATA STUDENT MEETS ALL REQUIREMENTS Sign at Step 5 and return this form to school. Or STUDENT DOES NOT MEET ALL REQUIREMENTS FIFTH DOSE Mo/Day/Yr Check the appropriate box below, sign at Step 5, and return this form to school. PLEASE NOTE THAT INCOMPLETEY IMMUNIZED STUDENTS MAY BE EXCLUDED FROM SCHOOL IF AN OUTBREAK OF ONE OF THESE DISEASES OCCURS. Although my child has NOT received ALL required doses of vaccine, the FIRST DOSE(S) has/have been received. I understand that the SECOND DOSE(S) must be received by the 90th school day after admission to school this year, and that the THIRD DOSE(S) and FOURTH DOSE(S) if required must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in writing each time my child receives a dose of required vaccine. NOTE: Failure to stay on schedule and notify the school may result in court action and a fine of up to $25.00 per day of violation. WAIVERS (List in Step 2 above, the date(s) of any immunizations your child has already received) For health reasons this student should not receive the following immunizations SIGNATURE - Physician For religious reasons this student should not be immunized. Date Signed For personal conviction reasons this student should not be immunized. LIST VACCINE(S) WAIVED SIGNATURE Step 5 This form is complete and accurate to the best of my knowledge. Check one: ( I do I do not ) give permission to share my child s current immunization records and as they are updated in the future with the Wisconsin Immunization Registry (WIR). I understand that I may revoke this consent at any time by sending written notification to the school district. Following the date of revocation, the school district will provide no new records or updates to the WIR. SIGNATURE - Parent/Guardian/Legal Custodian or Adult Student Date Signed 12

9 DEPARTMENT OF HEALTH SERVICES Division of Public Health P (Rev. 07/11) STATE OF WISCONSIN s , Wis. Stats. STUDENT IMMUNIZATION LAW AGE/GRADE REQUIREMENTS SCHOOL YEAR The following are the minimum required immunizations for each age/grade level. It is not a recommended immunization schedule for infants and preschoolers. For that schedule, contact your doctor or local health department. Age/Grade Number of Doses Pre K (2 yrs through 4 yrs) 4 DTP/DTaP/DT 2 3 Polio 3 Hep B 1 MMR 5 1 Var 6 Grades K through 4 4 DTP/DTaP/DT/Td 1 4 Polio 4 3 Hep B 2 MMR 5 2 Var 6 Grades 5 4 DTP/DTaP/DT/Td 2 4 Polio 4 3 Hep B 2 MMR 5 1 Var 6 Grades 6 through 10 4 DTP/DTaP/DT/Td 2 1 Tdap 3 4 Polio 4 3 Hep B 2 MMR 5 2 Var 6 Grades 11 4 DTP/DTaP/DT/Td 2 1 Tdap 3 4 Polio 4 3 Hep B 2 MMR 5 1 Var 6 Grade 12 4 DTP/DTaP/DT/Td 2 1 Tdap 3 4 Polio 4 3 Hep B 2 MMR 5 2 Var 6 1. DTP/DTaP/DT vaccine for children entering Kindergarten: Your child must have received one dose after the 4 th birthday (either the 3 rd, 4 th, or 5 th dose) to be compliant. (Note: a dose 4 days or less before the 4th birthday is also acceptable). 2. DTP/DTaP/DT/Td vaccine for students entering Pre K and grades 1 through 12: Four doses are required. However, if your child received the 3 rd dose after the 4 th birthday, further doses are not required. (Note: a dose 4 days or less before the 4th birthday is also acceptable). 3. Tdap means adolescent tetanus, diphtheria and acellular pertussis vaccine. If your child received a dose of a tetanus-containing vaccine, such as Td, within 5 years of entering the grade in which Tdap is required, your child is compliant and a dose of Tdap vaccine is not required. 4. Polio vaccine for students entering grades Kindergarten through 12: Four doses are required. However, if your child received the 3 rd dose after the 4 th birthday, further doses are not required. (Note: a dose 4 days or less before the 4 th birthday is also acceptable). 5. The first dose of MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1 st birthday is also acceptable). 6. Var means Varicella (chickenpox) vaccine. A history of chickenpox disease is also acceptable.

10 DISTRICT OFFICE 300 Hillcrest Street PO Box 1500 Ellsworth, WI Fax August 2012 Dear Parent/Guardian: Re: Free and Reduced Lunch and Breakfast Programs If you think your children may be eligible to receive free or reduced-price meals under the National School Lunch Program or School Breakfast Program, please take the time to fill out and submit the attached application. Please carefully read the attached application as there have been changes from the past application. If is important that eligible families apply in order to ensure children are receiving a nutritious breakfast and lunch on a daily basis. Experts say that children who don t get basic nutrition every day don t achieve as well in school as those who do get good nutrition. It is also vital for our school district to identify all students who are eligible for free and reduced lunch, even if your child does not use our food service program (i.e. Panther Pre-School children who walk home for lunch, and children who bring their own lunch). Free and reduced numbers directly impact the state aid we receive for several school programs. All applications and information gathered will be private and confidential. Children s names are kept confidential and no identifying information regarding free or reduced-price meals appears on the computer used in the lunch rooms. Please send applications to: Sharlene Kreye, School Nurse Ellsworth Community School District P.O. Box 1500 Ellsworth, WI Sincerely, Barry Cain, Superintendent ELLSWORTH HIGH SCHOOL 323 Hillcrest Street Ellsworth, WI Fax ELLSWORTH MIDDLE SCHOOL 312 West Panther Drive Ellsworth, WI Fax HILLCREST ELEMENTARY 350 South Grant Street Ellsworth, WI Fax PRAIRIE VIEW ELEMENTARY W th Avenue Hager City, WI Fax LINDGREN EARLY LEARNING CENTER N3470 U.S. Hwy. 63 Hager City, WI The Ellsworth Fax Community School District does not The Ellsworth discriminate Community on School the basis District of sex, does race, not color, discriminate religion, on the basis national of sex, origin, race, color, ancestry, religion, creed, national pregnancy, origin, marital ancestry, or creed, pregnancy, parental marital status, or sexual parental orientation, status, sexual or physical, orientation, mental, or physical, emotional mental, emotional or learning or disability. learning disability.

11 Free and Reduced Lunch and Breakfast Program Dear Parent/Guardian: Children need healthy meals to learn. The Ellsworth Community School District offers healthy meals every school day. Breakfast costs $1.70; lunch costs $2.50 for middle and high school and $2.30 for elementary. Your children may qualify for free meals or for reduced price meals. Reduced price is $.30 for breakfast and $.40 for lunch. 1. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: Sharlene Kreye, P.O. Box 1500, Ellsworth, WI WHO CAN GET FREE MEALS? All children in households receiving benefits from FoodShare, the Food Distribution Program on Indian Reservations (FDPIR) or W-2 Cash Benefits, can get free meals regardless of your income. Also, your children can get free meals if your household s gross income is within the free limits on the Federal Income Eligibility Guidelines. 3. CAN FOSTER CHILDREN GET FREE MEALS? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income. 4. CAN HOMELESS, RUNAWAY, AND MIGRANT CHILDREN GET FREE MEALS? Yes, children who meet the definition of homeless, runaway, or migrant qualify for free meals. If you haven t been told your children will get free meals, please call or Jessica Wiskow, homeless liaison at or to see if they qualify. 5. WHO CAN GET REDUCED PRICE MEALS? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Eligibility Guidelines, shown on this application. 6. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE APPROVED FOR FREE MEALS? Please read the letter carefully and follow the instructions. Call Sharlene Kreye at if you have questions. 7. MY CHILD S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT ANOTHER ONE? Yes. Your child s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year. 8. I GET WIC. CAN MY CHILD(REN) GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application. 9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof. 10. IF I DON T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit. 11. WHAT IF I DISAGREE WITH THE SCHOOL S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: PAUL UHREN, P.O. BOX 1500, ELLSWORTH, WI 54011, MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You or your child(ren) do not have to be U.S. citizens to qualify for free or reduced price meals.

12 13. WHO SHOULD I INCLUDE AS MEMBERS OF MY HOUSEHOLD? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children living with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them. 14. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income. 15. WE ARE IN THE MILITARY. DO WE INCLUDE OUR HOUSING ALLOWANCE AS INCOME? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. 16. MY SPOUSE IS DEPLOYED TO A COMBAT ZONE. IS HIS/HER COMBAT PAY COUNTED AS INCOME? No, if the combat pay is received in addition to his/her basic pay because of his/her deployment and it wasn t received before s/he was deployed, combat pay is not counted as income. Contact your school for more information. 17. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for FoodShare or other assistance benefits, contact your local assistance office or call If you have other questions or need help, call SHARLENE Si necesita ayuda, por favor llame al teléfono: SHARLENE Si vous voudriez d aide, contactez nous au numero: SHARLENE Sincerely, Barry Cain, Superintendent

13 INSTRUCTIONS FOR APPLYING Part 1: All Household Members (a household member is any child or adult living with you): All applicants should complete this part. List the name of each household member, the name of the school each child attends, and the child s grade. If the child is a foster child, check the box for foster child. If a household member has no income, check the box for no income. All household members, including foster children, should be included here. If you need additional space, attach a separate piece of paper. If anyone in your household receives benefits from FoodShare, W-2 Cash Benefits, or the Food Distribution Program on Indian Reservations (FDPIR), follow these instructions. Part 2: List the case number for one household member (adult or child) who receives FoodShare or W-2 Cash Benefits or FDPIR benefits. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. You do not need to provide the last four digits of your Social Security Number. Part 6: This question is optional. You can choose whether or not to provide ethnic and racial data. If you are applying for a child who is homeless, a migrant or runaway, follow these instructions. Part 2: Skip this part. Part 3: Check the appropriate category and call Jessica Wiskow, homeless Part 4: Skip this part. Part 5: Sign the form. You do not need to provide the last four digits of your Social Security Number. Part 6: This question is optional. You can choose whether or not to provide ethnic and racial data. If you are applying for only foster child(ren), follow these instructions. You do not need to fill out a separate application for each foster child in your household. (If there are both foster children and non-foster children in your household, follow the instructions below for All Other Households). If all children in the household are marked as foster children in Part 1: Part 2: Skip this part. Part 3: Skip this part. Part 4: Skip this part. Part 5: Sign the form. You do not need to provide the last four digits of your Social Security Number. Part 6: This question is optional. You can choose whether or not to provide ethnic and racial data. ALL OTHER HOUSEHOLDS, including WIC households and households with both foster children and non-foster children, follow these instructions: Part 2: Skip this part. Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call Jessica Wiskow, homeless If not, skip this part. Part 4: Follow these instructions to report total household income from this month or last month. Section 1 Name: List all household members who have income. Section 2 Gross Income and How Often It Was Received: List the income for each household member. Check the box to tell us how often the person receives the income weekly, every other week, twice a month, or monthly. o Earnings from work: List the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. Net income should only be reported for self-owned business, farm, or rental income. o Welfare, Child Support, Alimony: List the amount each person receives, and check the box to tell us how often. o Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran s benefits (VA benefits), and disability benefits. List the amount each person receives, and check the box to tell us how often they receive it. o All Other Income: List Worker s Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income received weekly, every other week, twice a month, monthly, quarterly, or annually. Do not include income from FoodShare, FDPIR, WIC, Federal education benefits and foster payments received by your family from the placing agency. o If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income. Part 5: An adult household member must sign the form and list the last four digits of their Social Security Number (or write none if s/he doesn t have one). Writing none does not prevent your child(ren) from qualifying to receive free or reduced priced meals. Part 6: This question is optional. You can choose whether or not to provide ethnic and racial data.

14 PART 1. ALL HOUSEHOLD MEMBERS FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION Names of all people living in your household (First, Middle Initial, Last) School the child attends, or indicate NA if household member is not in school Grade Check if a foster child (legal responsibility of welfare agency or court) If all children listed below are foster children, skip to Part 5 to sign this form. Check if NO income PART 2. BENEFITS If any member of your household receives FoodShare, FDPIR or W-2 Cash Benefits, provide the name and case number for the person who receives benefits and skip to part 5. If no one receives these benefits, go to Part 3. NAME: CASE NUMBER: PART 3. HOMELESS, MIGRANT, RUNAWAY STATUS If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call Jessica Wiskow, homeless HOMELESS MIGRANT RUNAWAY PART 4. TOTAL HOUSEHOLD GROSS INCOME (before deductions). List all income on the same line as the person who receives it. Check the box for how often it is received. Record each income only once. If you provided a case number in Part 2, you do not need to provide income information. 1. NAME (List only household members with income) 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED Earnings from work before deductions. Weekly Every 2 Weeks Twice Monthly Monthly Welfare, child support, alimony Weekly Every 2 Weeks Twice Monthly Monthly Pensions, retirement, Social Security, SSI, VA benefits Weekly Every 2 Weeks Twice Monthly Monthly All Other Income (indicate frequency, such as weekly monthly quarterly annually ) (Example) Jane Smith $200 $150 $0 $50 / quarterly $ $ $ $ / $ $ $ $ / $ $ $ $ / $ $ $ $ / $ $ $ $ / $ $ $ $ / PART 5. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN) An adult household member must sign the application. If Part 4 is completed, the adult signing the form also must list the last four digits of his or her Social Security Number or write none if you do not have a Social Security Number. (See Privacy Act Statement on the back of this page.) I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted. Sign here: Print name: Date: Address: City: State: Zip Code: Phone Number: Cell Phone Number: Last four digits of Social Security Number (Write None if you do not have a Social Security Number): * * * - * * - PART 6. CHILDREN S ETHNIC AND RACIAL IDENTITIES (OPTIONAL) Choose one ethnicity: Hispanic/Latino Not Hispanic/Latino Choose one or more (regardless of ethnicity): Asian American Indian or Alaska Native Black or African American White Native Hawaiian or other Pacific Islander DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY.

15 Hispanic/Latino Not Hispanic/Latino Asian American Indian or Alaska Native Black or African American White Native Hawaiian or other Pacific Islander DO NOT FILL OUT THIS PART. THIS IS FOR SCHOOL USE ONLY. Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 Total Income: Per: Week Every 2 Weeks Twice A Month Month Year Household size: Categorical Eligibility: Date Withdrawn: Eligibility: Free Reduced Denied Reason: Determining Official s Signature: Date: Confirming Official s Signature: Verifying Official s Signature: Date: Date: Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart. 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 is not required when you apply on behalf of a foster child or you list a FoodShare, W-2 Cash Benefits 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. FEDERAL ELIGIBILITY INCOME CHART For School Year Household Yearly Monthly Weekly size 1 $20,665 $1,723 $398 2 $27,991 $2,333 $539 3 $35,317 $2,944 $680 4 $42,643 $3,554 $821 5 $49,969 $4,165 $961 6 $57,295 $4,775 $1,102 7 $64,621 $5,386 $1,243 8 $71,947 $5,996 $1,384 Each additional person: $7,326 $611 $141 Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C or call toll free (866) (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer

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