Embed Size (px)
Citation preview
NCUSD203 2014-2015 Centralized Enrollment Office rev 4.28.14
EnrollmentDocumentationRequirementsINSTATETRANSFER
HighSchool
PleasefindbelowalistofrequireddocumentsnecessarytoenrollyourstudentinNapervilleSchoolDistrict203.
ENROLLMENTDOCUMENTS EnrollmentForm BirthCertificate–originalorcertifiedcopy HomeLanguageSurvey NeedsAssessmentofSpecialEducation,EarlyInterventionorGiftedStudents DenialofPermissionsforPublications,MediaReleases,DirectoryInformationandMilitaryRecruitment ParentalConsentforReleaseofRecords EmergencyCard–TobecompletedatCentralizedEnrollmentOffice ISBEStudentTransferFormiftransferringfromanotherIllinoispublicschool*
ORCertification,inwriting,iftransferringfromaprivateoroutofstateschool,thatthestudentisingoodstanding‐i.e.notcurrentlyservingasuspensionorexpulsion*
*Providedbyschoolfromwhichstudentistransferring
NE
W S
TU
DE
NT
EN
RO
LL
ME
NT
ST
UD
EN
T
ID
HO
USE
HO
LD
NA
ME
GR
ID
CO
DE
E
NR
OL
LM
EN
T
DA
TE
E
NR
OL
LM
EN
T S
CH
OO
L
EN
RO
LL
ME
NT
G
RA
DE
G
RA
D
YE
AR
H
OM
E S
CH
OO
L
TO
DA
Y’S
D
AT
E
AB
OV
E IN
FOR
MA
TIO
N F
OR
OFF
ICE
USE
ON
LY
NA
PER
VIL
LE
CO
MM
UN
ITY
UN
IT S
CH
OO
L D
IST
RIC
T 2
03 E
NR
OL
LM
EN
T F
OR
M
A V
AL
ID B
IRT
H C
ER
TIF
ICA
TE
AN
D P
RO
OF
OF
RE
SID
EN
CY
MU
ST B
E P
RO
VID
ED
FO
R A
LL
EN
TE
RIN
G S
TU
DE
NT
S A
T T
HE
TIM
E O
F E
NR
OL
LM
EN
T.
PL
EA
SE P
RIN
T A
ND
CO
MPL
ET
E B
OT
H S
IDE
S
STU
DE
NT
’S L
EG
AL
NA
ME
as i
t app
ears
on
the
birt
h ce
rtifi
cate
(L
ast,
Firs
t, M
iddl
e)
BIR
TH
DA
TE
B
IRT
HPL
AC
E (C
ITY
/ST
AT
E/C
OU
NT
RY
) G
EN
DE
R
A
GE
ET
HN
ICIT
Y
1.
His
pani
c/La
tino
(Mus
t cho
ose
one)
No
(If n
o, c
hoos
e ra
ce b
elow
)
Yes
RA
CE
2.
R
ace
(Cho
ose
one
or m
ore)
Am
eric
an In
dian
or A
lask
an N
ativ
e
Asi
an
B
lack
or A
fric
an A
mer
ican
Nat
ive
Haw
aiia
n or
Oth
er P
acifi
c Is
land
er
W
hite
E
NR
OL
LM
EN
T
GR
AD
E
____
____
____
____
____
__
M
OT
HE
R’S
MA
IDE
N
NA
ME
__
____
____
____
____
____
ME
DIC
AID
NO
. (I
F A
PPL
ICA
BL
E)
IF B
OR
N O
UT
SID
E U
.S.:
DA
TE
EN
TE
RE
D U
.S. _
____
____
____
____
____
____
____
____
____
____
____
____
____
__
DA
TE
EN
TE
RE
D F
IRST
U.S
. SC
HO
OL
____
____
____
____
____
____
____
____
____
_ __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Sc
hool
City
Sta
te
Dis
trict
Gra
de
DA
TE
EN
TE
RE
D F
IRST
ILL
INO
IS S
CH
OO
L _
____
____
____
____
____
____
____
_ __
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Sc
hool
City
Sta
te
Dis
trict
Gra
de
STR
EE
T A
DD
RE
SS IN
DIS
TR
ICT
203
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_ A
ddre
ss
A
pt. #
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_ C
ity
S
tate
Z
ip
WH
AT
DIS
TR
ICT
203
SC
HO
OL
(if a
ny) H
AS
YO
UR
ST
UD
EN
T E
VE
R A
TT
EN
DE
D?
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Sc
hool
Gra
de
Y
ear
MO
ST R
EC
EN
T S
CH
OO
L A
TT
EN
DE
D
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Scho
ol
C
ity
S
tate
D
istri
ct
G
rade
PAR
EN
T/G
UA
RD
IAN
ST
UD
EN
T L
IVE
S W
ITH
(P
AR
EN
T #
1)
RE
LA
TIO
NSH
IP T
O S
TU
DE
NT
PA
RE
NT
/GU
AR
DIA
N S
TU
DE
NT
LIV
ES
WIT
H
(PA
RE
NT
#2)
R
EL
AT
ION
SHIP
TO
ST
UD
EN
T
C
EL
L P
HO
NE
#
H
OM
E P
HO
NE
#
W
OR
K P
HO
NE
#
(
)
(
)
(
)
C
EL
L P
HO
NE
#
H
OM
E P
HO
NE
#
WO
RK
PH
ON
E #
(
)
(
)
(
) PR
IMA
RY
EM
AIL
AD
DR
ESS
:___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_ PR
IMA
RY
EM
AIL
AD
DR
ESS
:___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_
JOIN
T/N
ON
-CU
STO
DIA
L P
AR
EN
T/G
UA
RD
IAN
RE
LA
TIO
NSH
IP T
O S
TU
DE
NT
C
EL
L P
HO
NE
#
H
OM
E P
HO
NE
#
WO
RK
PH
ON
E #
(
)
(
)
(
)
AD
DR
ESS
, CIT
Y, S
TA
TE
, ZIP
LE
GA
L R
IGH
TS
TO
DIS
TR
ICT
MA
ILIN
GS
YE
S
N
O
PRIM
AR
Y E
MA
IL A
DD
RE
SS:_
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
MU
ST P
RO
VID
E C
UST
OD
Y D
OC
UM
EN
TS/
PAR
EN
TIN
G A
GR
EE
ME
NT
, if a
pplic
able
.
(OV
ER
)
FOR
M D
AT
ED
4.
24.1
4
PAG
E 2
SI
BL
ING
S
NA
ME
(LA
ST, F
IRST
, MID
DL
E)
GE
ND
ER
B
IRT
HD
AT
E
SC
HO
OL
G
RA
DE
The
info
rmat
ion
with
in th
is d
ocum
ent i
s cor
rect
and
to th
e be
st o
f my
know
ledg
e.
X
SI
GN
AT
UR
E O
F PA
RE
NT
/GU
AR
DIA
N
“Sch
ool D
istr
ict 2
03 d
oes n
ot d
iscr
imin
ate
on th
e ba
sis o
f sex
in e
duca
tiona
l pro
gram
s or
activ
ities
and
is r
equi
red
by T
itle
IX o
f the
Fed
eral
Edu
catio
n A
men
dmen
ts o
f 197
2 an
d Pa
rt 8
6.0
of th
e re
gula
tions
is
sued
ther
e un
der
not t
o di
scri
min
ate
in su
ch m
anne
r.”
All
stud
ents
are
req
uire
d by
Sta
te la
w to
obt
ain
a ph
ysic
al e
xam
inat
ion
from
a li
cens
ed p
hysi
cian
pri
or to
ent
ranc
e in
to K
inde
rgar
ten,
Gra
de 6
and
Gra
de 9
. It
is a
lso
requ
ired
by
Stat
e L
aw to
obt
ain
a de
ntal
e
xam
inat
ion
from
a li
cens
ed d
entis
t pri
or to
ent
ranc
e in
to K
inde
rgar
ten,
Gra
de 2
and
Gra
de 6
. T
rans
fer
stud
ents
are
allo
wed
30
days
to c
ompl
y w
ith th
is r
equi
rem
ent.
IN C
ASE
TH
E P
AR
EN
T/G
UA
RD
IAN
CA
NN
OT
BE
RE
AC
HE
D, Y
OU
R L
OC
AL
EM
ER
GE
NC
Y C
ON
TA
CT
MA
Y B
E C
AL
LE
D.
IF N
ON
E A
RE
LIS
TE
D, 9
11 W
ILL
BE
CA
LL
ED
.
EM
ER
GE
NC
Y 1
: C
ON
TA
CT
N
AM
E:
C
EL
L P
HO
NE
#
____
____
____
____
____
____
____
____
_
WO
RK
PH
ON
E #
___
____
____
____
____
____
____
___
MA
LE
___
____
F
EM
AL
E _
____
___
H
OM
E P
HO
NE
#
____
____
____
____
____
____
____
____
_
EM
ER
GE
NC
Y 2
: C
ON
TA
CT
N
AM
E:
CE
LL
PH
ON
E #
__
____
____
____
____
____
____
____
___
W
OR
K P
HO
NE
# _
____
____
____
____
____
____
____
_
MA
LE
___
____
F
EM
AL
E _
____
___
H
OM
E P
HO
NE
#
____
____
____
____
____
____
____
____
_
Spec
ial i
nstr
uctio
n in
cas
e of
an
emer
genc
y if
you
cann
ot b
e re
ache
d.
I aut
hori
ze th
is sc
hool
to se
ek th
e ne
cess
ary
emer
genc
y ca
re a
nd tr
eatm
ent f
or m
y ch
ild w
hene
ver
thos
e in
divi
dual
s des
igna
ted
abov
e ar
e no
t ava
ilabl
e fo
r co
nsul
tatio
n or
dir
ectio
n.
SIG
NA
TU
RE
OF
PAR
EN
T/G
UA
RD
IAN
St
uden
t req
uest
for
the
loan
of t
extb
ooks
. I h
ereb
y re
ques
t the
loan
of s
ecul
ar te
xtbo
oks i
n ac
cord
ance
with
Pub
lic A
ct 7
9-96
1 of
197
5. I
und
erst
and
that
this
req
uest
will
rem
ain
valid
so lo
ng a
s a st
uden
t is e
nrol
led
in th
is sc
hool
and
that
I m
ay a
t any
tim
e w
ithdr
aw th
is r
eque
st.
SIG
NA
TU
RE
OF
PAR
EN
T/G
UA
RD
IAN
R
ev.
4.24
.14
X
X
NCUSD203 Centralized Enrollment Office Rev 6.23.14
Naperville Community Unit School District 203 Home Language Survey
Student’s Legal Name:__________________________________________________________________________________________ (First name) (Last name) Date of Birth :_____________ School Grade:________ Male Female
Address:___________________________________________________________________ Home Phone:______________________ Father’s Name:_________________________________________ Cell Phone:____________________ (First name) (Last name)
Mother’s Name:_________________________________________ Cell Phone:_____________________ (First name) (Last name)
MOST RECENT SCHOOL ATTENDED _____________________________________________________________________________ _ School City State District Grade
The state of Illinois requires each district to collect a Home Language Survey for every new student. This information is used to count the students whose families speak a language other than English at home. The Home Language Survey also helps to identify students who need to be assessed for English language proficiency. If the answer to either question #1 or #2 below is “YES,” the Illinois School Code requires the school to assess your child’s English language proficiency.
1. Is a language other than English spoken in your home? No Yes What language? (Infinite Campus Entry: Home Language/Native Language)
2. Does your child speak a language other than English? No Yes What language? (If yes, answer 2a and 2b.) (Infinite Campus Entry: Home Language/Native Language)
2a. Does your child read in this language? No Yes 2b. Does your child write in this language? No Yes
3. Was the student ever in a Bilingual, Dual Language or ESL Program? No Yes (If yes, please answer questions 3a and 3b.)
3a. Please indicate which program: Bilingual Dual Language ESL 3b. Please mark the grade(s) in which the student was in a Bilingual, Dual Language or an ESL Program:
PreK K 1 2 3 4 5 6 7 8 9 10 11 12
4. Indicate your preferred language for communication. English Spanish
___________________________________ _______________ (Signature of parent or guardian) (Date)
Send copy to Office of Language Learning: [email protected], [email protected] and [email protected] for all grade levels
[email protected] for junior high [email protected] for high school
NCUSD203 Centralized Enrollment Office rev 11.19.13
Naperville Community Unit School District 203 Needs Assessment of
Special Education, Early Intervention or Gifted Students To: Parents of New Students enrolled in Naperville Community Unit School District 203
Re: Individual Special Education Needs
Date: Student’s Name: School:
Phone number(s): Grade: ID#
Please examine the questions below and provide us with information to best address your child’s individual needs. This information will help us to make the most appropriate placement and to have the necessary supports and programs in place as needed. Please answer the following questions by circling the correct response. If you circle YES, please give specific information after the question.
Does your child have a current IEP and receive special education services? Yes No
*If yes, please provide a copy of your child’s IEP (Individualized Education Program) Has your child ever been enrolled in a special education program? Yes No
Has your child ever had private or school-based speech or language therapy? Yes No
Has your child ever had private or school-based occupational or physical therapy? Yes No
Has your child received early intervention to address any learning difficulties? Yes No
Has your child ever been evaluated for possible learning difficulties? Yes No
Do you have concerns about your child’s learning and achievement that need Yes No
to be reviewed by the school? Has your child ever been evaluated or placed in a gifted program? Yes No
If your child is transported to school in a wheelchair, please indicate here and Yes No
request a “wheelchair information” form.
Please provide us with any additional information regarding your child’s individual or special academic or social needs. If there are any special considerations that would affect educational progress, please list them below.
PERMISSIONS: Please select the categories that apply or indicate no restrictions. Public events, such as concerts, com-munity activities, awards, athletics, superintendent visits, etc. are excluded from this permissions denial. Unrestricted: I have read the above statements and agree to my student’s participation WITHOUT restrictions. (Proceed to Directory Section)
Full Denial: I DENY PERMISSION for use of student’s full name, InDIvIDual Image and nameD work except when the event is deemed public, as described above. (Proceed to Directory Section)
Image: I DENY PERMISSION for use of an InDIvIDual Image. I understand this denial does not apply to photos where my student appears as part of a group.
Full Name: I DENY PERMISSION for use of a full name. This does not exclude the use of first name with last initial only.
Work Product: I DENY PERMISSION for nameD work to be shared.
we are very proud of our students and their accomplishments, and we enjoy highlighting their work and activities. In publicizing and supporting learning, events, programs, services and recognitions that take place within our schools or for our students, there will be times when the district will share information through broadcast, print, web site and social media postings. The purpose of this form is to make you aware of these requests and to allow you to remove your student from involvement. Permission preferences indicated on this form will remain in a student’s record unless you submit a Changed Permissions Status Form (available at the school office). If a Permission Denial form is NOT FILED, then UNRESTRICTED permission is applied.
Naperville School DiStrict 203203 W. hillSiDe roaD, Naperville, il 60540
ceNtralizeD eNrollmeNt office 630-548-4320
Denial of Permissions Form for 2014-2015for Publications, media releases, Directory Information and military recruitment
Student name__________________________________ School_______________________________________
Student I.D. number___________________ grade_______Home Phone________________________________
Parent/guardian Signature_____________________________________________Date____________________
SCHOOL DIRECTORY: The following denial concerns Home&School directories which contain student information. I do NOT give permission to use my student’s name, parent/guardian name, address, telephone or email address in any school directory (print/electronic). Does not apply to information kept for official school district use.
HIgH SCHOOL JUNIORS aND SENIORS ONLY: federal law requires a student’s name, address and telephone number to be released to military recruiters unless the parent/guardian objects in writing.
I do NOT give permission for my student’s information to be released to military recruiters.
or choose from the following:
NCUSD 203 Centralized Enrollment Office 11-19-13
Please read and complete aLL SECTIONS of the Permission Denial Form.
NOTICE: I understand requesting my student to be excluded from any or all of the above DOES NOT EXCLUDE the publishing of my student’s name, portrait, works or other photographs in the school yearbook.
NCUSD203 Centralized Enrollment Office 12.6.12
Dan Bridges, Superintendent
NAPERVILLE COMMUNITY UNIT SCHOOL DISTRICT 203
Administrative Center | 203 West Hillside Road | Naperville, Illinois 60540-6589
PARENTAL CONSENT FOR RELEASE OF STUDENT RECORDS
Date:
Student Name: DOB:
Has enrolled at in __________ grade. District 203 School
I hereby authorize: ___________________________________ Phone: Name of School
___________________________________ Fax: Street Address
___________________________________ City, State, Zip
To release to the following information on the above named
student:
Academic Transcript including key to grading system
Grades to date of leaving
Standardized Test Data
Health Records
Special Education Records (if applicable)
ISBE Transfer Form or Letter of Good Standing
SEND RECORDS TO: REGISTRAR (to be completed by
Enrollment Office)
Naperville, IL 60540-6589
__________________________________ _________________
Parent/Guardian Signature Date The Federal Register Volume 41, No, 118 Section 99.31 of June 17, 1976, states that prior consent for the disclosure of school records is not required if the
disclosure is to officials of another school or school system in which the student seeks or intends to enroll.
Naperville CUSD 203 Apply for Free and Reduced
Meal Benefits Online!
Dear Parent/Guardian,
Naperville CUSD 203 is pleased to announce the availability of applying for Free and Reduced Price Meals online! The process is SAFE, SECURE, PRIVATE, and AVAILABLE anytime, anywhere!
Safe & Secure
We use the highest level of data encryption available, meaning that your information is always safe and guarded.
Private & Available
Apply online in the privacy of your own home. The online service is available 24/7 anytime, anywhere there is an Internet connection!
Fast
Your data is transmitted to the Naperville CUSD 203 Business Office the same day you apply, allowing for quicker processing so you can receive benefits faster.
Go Green
No more paper applications to complete and return to the school office! Applying online is so convenient and good for the environment as well!
• Visit www.heartlandapps.com • Select your State (IL) and then your School District (Naperville CUSD 203) • Follow the easy to use, step-by-step screens to enter student and household
information • Click "Apply" to submit your application for meal benefits!
The First Day of School is August 20 Online Application Entry will be available beginning July 23
Please note that all applications are subject to verification
Dear Parent/Guardian:
Children need healthy meals to learn. Naperville CUSD 203 offers healthy meals every school day. Breakfast costs $ N/A • lunch costs $ varies . Your children may qualify for free meals or for a reduced price meals. Reduced price is $ N/A for breakfast and $ .40 for lunch. To apply for free or reduced-price meals, use the Household Eligibility Application, which is enclosed. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: your school or to NCUSD203 / 203 W Hillside Rd / Naperville, IL 60540
Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart.
Income Eligibility Guidelines Effective from July 1, 2014, to June 30, 2015
Reduced-Price Meals 185% Federal Poverty Guideline
Household Size Annual Monthly Twice Per
Month Every Two
Weeks Weekly
1 21,590 1,800 900 831 416
2 29,101 2,426 1,213 1,120 560
3 36,612 3,051 1,526 1,409 705
4 44,123 3,677 1,839 1,698 849
5 51,634 4,303 2,152 1,986 993
6 59,145 4,929 2,465 2,275 1,138
7 66,656 5,555 2,778 2,564 1,282
8 74,167 6,181 3,091 2,853 1,427
For each additional family member, add
7,511 626 313 289 145
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 Household Eligibility Application for all students in your household per district. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to the school.
2. WHO CAN GET FREE MEALS? All children in households receiving benefits from Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) and/or are foster children that are under the legal responsibility of a foster care agency or court are eligible for 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. Children who meet the definition of homeless, runaway, or migrant also qualify for free meals. If you haven't been told your children will get free meals, please contact your school to see if your child(ren) qualifies.
3. 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 Eligibility Income Chart, shown above.
4. A MEMBER OF MY HOUSEHOLD RECEIVED SNAP OR TANF BENEFITS. THE SCHOOL SENT A LETTER STATING THAT MY CHILD IS AUTOMATICALLYAPPROVED FOR FREE MEALS BASED ON DIRECT CERTIFICATION. DO I NEED TO DO ANYTHING MORE TO ENSURE THAT MY CHILD RECEIVES FREE MEALS? No. You do not need to do anything more to receive free meals for your child. If you have students not listed on the letter, contact the school immediately. If you do not wish to receive the free meals, you should follow the steps outlined in the letter from the school to notify school personnel immediately.
5. 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.
6. 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 the enclosed application.
7. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof.
8. 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
9. 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 the person listed above.
10. 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.
11. 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.
12. 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.
13. 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.
14. MY SPOUSE IS DEPLOYED TO A COMBAT ZONE. IS HER COMBAT PAY COUNTED AS INCOME? No, if the combat pay is received in addition to her basic pay because of her deployment and it wasn't received before she was deployed, combat pay is not counted as income. Contact your school for more information.
15. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for SNAP, TANF or other assistance benefits, contact your local Department of Human Services office or call (800) 843-6154 (voice) or (800) 447-6404 (TTY).
Sincerely,
ISBE 68-06 NSLP SBP (6/14) Page 1 of 3
INSTRUCTIONS FOR APPLYING - COMPLETE ONE APPLICATION PER HOUSEHOLD PER SCHOOL DISTRICT
IF YOUR HOUSEHOLD RECEIVES SNAP OR TANF BENEFITS, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
Part 1: List all household members, school and grade for each student, and a SNAP or TANF case number for any household member including adults receiving such
benefits. (Attach another sheet of paper if necessary.) .
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. (The last four digits of a Social Security Number are not necessary.)
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
IF NO ONE IN YOUR HOUSEHOLD GETS SNAP OR TANF BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY OR HEAD
START/EVEN START, FOLLOW THESE INSTRUCTION AND RETURN THE COMPLETE FORM TO YOUR SCHOOL:
Part 1: List all household members and the name of school for each child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Complete only if a child in your household isn't eligible under Part 2. See instructions for All Other Households.
Part 4: Sign the form. Only if part 3 is completed, please include the last four digits of a Social Security Number. (or mark the box if s/he doesn't have one).
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS AND RETURN THE COMPLETED FORM TO YOUR SCHOOL:
If children in the household are foster children that are the legal responsibility of a foster care agency or court:
Part 1: List all foster children and the school name for each child. Check the "Foster Child" box for each foster child.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
If some of the children in the household are foster children are foster children that are the legal responsibility of a foster care agency or court:
Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the "No Income" box. Check
the "Foster Child" box for each foster child.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Follow these instructions to report total household income from this month or last month.
• Box 1-Name: List all household members with income.
• Box 2 -Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to 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. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), and disability benefits. Under 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. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
Part 4: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn't have one).
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
ALL OTHER HOUSEHOLDS INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the name of school for each child. For any person, including children, with no income, you must check the "No Income" box.
Part 2: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call your school.
Part 3: Follow these instructions to report total household income from this month or last month.
• Box 1-Name: List all household members with income.
• Box 2 -Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. You must tell us how often the money is received—weekly, every other week, twice a month or monthly. For earnings, be sure to 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. For other income, list the amount each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), and disability benefits. Under 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. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. Do not include income from SNAP, FDPIR, WIC or Federal education benefits. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
Part 4: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesn't have one).
Part 5, 6, 7: Contact Information, Children's Racial and Ethnic Identities, and All Kids Information: Answer these questions if you choose to. (Optional)
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 Supplemental Nutrition Assistance Program (SNAP), 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.
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis 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 any program or activity conducted or funded by the USDA. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 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 by mail to the USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC 20250-9410, by fax (202) 690-7442 or email at program. [email protected]. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
ISBE 68-03 NSSTAP Application Instructions (6/14)
Page 2 of 3
Work Telephone Number (Include Area Code) Home Telephone Number (Include Area Code)
6. Children's Racial and Ethnic Identities (Optional)
Mark one ethnic identity: ❑ Hispanic/Latino ❑ Not HispanidLatino
Home Address (Number, Street, City, State, Zip Code)
❑ Native Hawaiian or Other Pacific Islander Mark one or more racial identities:
❑ Asian ❑ Black or African American ❑ White ❑ American Indian or Alaska Native
7. Sharing Application Information With All Kids—All Kids program is a complete healthcare program for every child in Illinois.
No! I DO NOT want information from my Household Eligibility Application shared with All Kids. Sign here:
— THE FOLLOWING SECTIONS ARE FOR SCHOOL USE ONLY—
LEAs must annualize income only when multiple incomes, at varying frequencies, are reported. Annual Income Conversion Weekly X 52 Every 2 Weeks X 26 Twice a Month X 24 Once a Month X 12
❑ Free based on: ❑ homeless ❑ migrant ❑ runaway ❑ Head Start
❑ SNAP or TANF ❑ foster child ❑ household's income
I:1 Reduced based on: ❑ household's income
ODenied—Reason: ❑ income too high ❑ incomplete application ❑ Non-qualifying SNAP/TANF
Date Withdrawn: Date: Signature of Determining Official
Every 2 Twice a
NUMBER IN
Per: ❑ Week ❑ Weeks ❑ Month ❑ Month ❑ Year HOUSEHOLD: CHANGE IN STATUS: Date
TOTAL INCOME
APPLICATION FOR FREE MILK/MEAL AND REDUCED-PRICE MEALS—Complete One Application Per Household Per School District. Instructions on back. , SCHOOL USE ONLY
1. All Household Members • Check if Error Prone Application
NAMES OF ALL HOUSEHOLD MEMBERS (for Student only) (for Student only) First, Middle Initial, Last School Name Grade
SNAP OR TANF CASE N M B R SkIPto par 4 if you saSNFor TANF case At least one SNAP/TANF must
be provided below.
if NO
Income
Check if Foster Child*
- - - . 111 - - - . El - - - . . - - - . . - - - . II
- - . .
2. Homeless, Migrant, Runaway, or Head Start (Categorically eligible) A foster child is the legal responsibility of a welfare agency or court.
❑ Homeless ❑ Migrant 0 Runaway n Head Start Signature of Your School Homeless Liaison, Migrant Coordinator, or Head Start Director
Date
3. Total Household Gross Income (before deductions) You must tell us how much and how often. A.
NAMES (LIST ALL HOUSEHOLD MEMBERS
WITH INCOME)
GROSS INCOME AND HOW OFTEN IT WAS RECEIVED (Example: $100/month, $100 /twice a month; $100/every other week; $100/week)
Earnings From Work (Before Deductions)
Welfare, Child Support, Alimony
Pensions, Retirement, Social Security
Worker's Comp., Unemploy-ment, SSI, etc. (An other income)
B. Amount How often? C. Amount How often? D. Amount How often? E, Amount How often?
I. $ $ $ $
ii. $ $ $
iii. $ $ $
iv. $ $ $
V. $ $ $ $
4. Signature and Social Security Number (Adult must sign)
An adult household member must sign the application. If Part 3 is completed or if no income is checked xxx-xx- Ei do not have a social —in Part1 , the adult signing the form must also list the last four digits his or her social security number — — — — — — — —
Social Security Number security number.
I certify (promise) all information on this application is true and all income is reported. I understand the school will get Federal funds based on the information I give. I understand school of-ficials may verify (check) the information. I understand if I purposely give false information, my children may lose meal benefits and I may be prosecuted.
Date
Printed Name of Adult Household Member
Signature of Adult Household Member
5. Contact Information (Optional)
THE FOLLOWING SECTIONS ARE NOT REQUIRED FOR SCHOOLS/DISTRICTS THAT ONLY PARTICIPATE IN ILLINOIS FREE AND/OR SPECIAL MILK PROGRAMS
Signature of Confirming Official
Date: CONFIRMATION (Prior to verification and only for those applications selected for verification.)
VERIFICATION
DIRECT VERIFICATION COMPLETED ❑ INITIAL DETERMINATION
❑ Free based on SNAP/ TANF case number
❑ Free based on income ❑ Reduced based on
income
VERIFICATION RESULTS:
0 No Change ❑ Free to Reduced ❑ Freeto Paid ❑ Reduced to Free 0 Reduced to Paid
REASON FOR CHANGE:
0 Income: $ DATE NOTICE OF STATUS CHANGE SENT: DATE VERIFICATION NOTICE SENT:
❑ Household Size:
CEFFECTIVE
H DATE OF STATUS
ANGE :
DATE RESPONSE DUE FROM HOUSEHOLD:
❑ Change in SNAP/TANF ❑ Did not respond ❑ Other: (recommend 10 calendar days)
DATE, METHOD, RESULTS OF FOLLOW-UP:
Results
❑ Telephone Date:
❑ Personal Contact Verifying Official's Si•nature
(recommend 3 business days)
68-03 School Year 2014-2015 NSSTAP (6 14)
Page 3 of 3
![HTP. Business Requirements Elicitation & Documentation [1.01, RUS]](https://img.pdfslide.tips/doc/110x75/58edb67b1a28ab2c2b8b45ef/htp-business-requirements-elicitation-documentation-101-rus.jpg)
