Sherwood School District 2016/2017 SHARING FREE OR REDUCED-PRICE INFORMATION WITH OTHER PROGRAMS Dear Parent/Guardian: If your student is eligible for free and reduced priced school meals, he or she may also qualify to receive other benefits. To give your permission for us to share your child’s name and meal eligibility status with staff in charge of the programs listed below, please select either option 1 or option 2. Select option 3 if you do not want to share your child’s eligibility status. Selecting any of these options will not change whether your student(s) get free or reduced price meals and is NOT A REQUIREMENT for participation in any of the school nutrition programs.

___ Option 1: Yes! Share my child(ren)’s eligibility status to all programs list below. ___ Option 2: Yes, for only the opportunities listed below: ___ Educational/School related program fee waiver/reduction – (Field trips, Educational workbooks, Registration fees, Elective Class Lab fees, College tuition fees, Summer School Fees, Fee pre-K fees, Outdoor School fee and PSAT/SAT/ACT fees) ___ School Athletic Programs fee waiver/reduction. ___ Other program fee waiver/reduction – (Medical/Dental Program fees) ____ Option 3: No! DO NOT share my child(ren)’s eligibility status with any programs. PLEASE NOTE – Listed benefits are NOT guaranteed by selecting the options above. Not all programs receive funding to provide fee waivers or reductions. I understand that I am releasing information (student’s name, F/R status, and/or contact information) which will show I applied for Free or Reduced-price benefits for my child(ren). I give up my rights to confidentiality for the programs checked above only. 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: _______________________________________________________ Address: ___________________________________________________________ Child’s Name: __________________________School: ______________________ Child’s Name: ___________________________School: _____________________ Child’s Name: ___________________________School: _____________________

For more information, you call the Sherwood Nutrition Services Department at 503-825-5151.

SHARING FREE OR REDUCED ENGLISH 16-17.pdf

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