2016-2017 Yamhill Carlton
Fee Reduction Request
Student Name: ______Date:______Grade ______
(Please Print Name)
I am requesting a reduction in fees for the following:
High School Athletics Registration Fees Test Fees Other ______
Specify
Fee Reductions may be granted based on Free and Reduced Meal Program status. The student for which the request submitted must qualify for Free Reduced Meal in order to qualify for a Fee Reduction at the time the request is submitted.Please complete the reverse side of this form to indicate permission to share information regarding the student's Free
Reduced Meal status with the appropriate District staff.
2016-2017 INCOME ELIGIBILITY GUIDELINES / is
Reduced Price Meals
Household Size / Annual / Monthly / Twice Per
Month / Every Two
Weeks / Weekly
-1- / 21,978 / 1,832 / 916 / 846 / 423
-2- / 29,637 / 2,470 / 1,235 / 1,140 / 570
-3- / 37,296 / 3,108 / 1,554 / 1,435 / 718
-4- / 44,955 / 3,747 / 1,874 / 1,730 / 865
-5- / 52,614 / 4,385 / 2,193 / 2,024 / 1,012
-6- / 60,273 / 5,023 / 2,512 / 2,319 / 1,160
-7- / 67,951 / 5,663 / 2,832 / 2,614 / 1,307
-8- / 75,647 / 6,304 / 3,152 / 2,910 / 1,455
For each additional family member add / 7,696 / 642 / 321 / 296 / 148
IMPORTANT NOTE: This Request Form is not a Free or Reduced Meal Application. Applications are available on- line at http://www.ycsd.kl2.or.us under the cafeteria link; at each school office, the District Office, or by mail. All forms should be returned to: Shiloh Ficek, YC District Office, 120 N. Larch Place, Yamhill, OR 97148. Ca11 503-
852-7610 for more information.
Office Use Only
Accepted: ______Date: ______
Accepted: ______Date: ______
Yamhill Carlton School District
SHARING FREE AND REDUCED MEAL STATUS INFORMATION WITH OTHER PROGRAMS
Dear Parent/Guardian:
The information you give on the Confidential Application for Free or Reduced Meals is only used to determine your student(s) eligibility for Free or Reduced meals. The information may also be used to determine your student(s) eligibility to receive benefits for other programs. For the following programs we must have your permission to share your information.
Sending in this form will not change whether your student(s) get free or reduced meals.
Signing this waiver is NOT A REQUIREMENT for participation in any school nutrition program.
__ No! I DO NOT want information from my Free and Reduced School Meals Application shared with any
of the programs listed below:
If you checked “NO”, stop here. You do not have to complete or send in this form. Your information will not be shared.
__ Yes! I DO want school officials to share information from my Free and Reduced School Meals
Application with: (Mark each program to which you want information released.)
___ High School Athletic Participation Fees
___ Registration Fees
___ Test Fees
___ Other (please specify) ______
If you marked any or all of the programs listed above, fill out the form below. I understand that I am releasing information (student’s name, F/R status, and/or contact information) to only the programs I have marked. I certify that I am the parent/legal guardian of the child(ren) for whom application is being made.
Signature of Parent/Guardian: ______Date: ______
Printed Name: ______
Mailing Address:
______City:______Zip:______
For more information, call Shiloh Ficek at 503.852.7160
Return this form to: YCSD, 120 N Larch Place, Yamhill, OR 97148