Free and Reduced Price Meals

2022-2023 Free and Reduced Price Meals

Please read through the linked document in order to view the full application before filling this form out and signing the form,

Complete one application per household.

Referenced documents: 2022 - 2023 Free and Reduced Lunch PDF

First Name

Last Name

Daytime Phone Number I would like to receive text notifications.

Street Address

Apt #

City

State

Zip

STEP 1: List A household members who are infants, children, and students up to and including grade 12 (if more spaces are needed pleas send an email to erin.arrigo@wasatchwaldorf.org with the additional children's information

Definition of Household Member. Anyone who is living with you and shares income an expenses, even if not related.

Children in Sate Foster Care and children who meet the definition of Homeless, Migrant, Runaway, or participate in Headstart programs are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.

Child #1 - First Name

Child #1 - Middle Initial

Child #1 - Last Name

Child #1 - Student

YesNo

Child #1 - Name of School/Center

Child #1 - Grade

Child # 1 - Check all that apply to child (skip if "no")

Head Start

Yes

Foster Child

Yes

Homeless, Migrant, Runaway

Yes

Child #2 - First Name

Child #2 - Middle Initial

Child #2 - Last Name

Child #2 - Student?

YesNo

Child #2 - Name of School/Center

Child #2 - Grade

Child # 2 - Check all that apply to child (skip if "no")

Head Start

Yes

Foster Child

Yes

Homeless, Migrant, Runaway

Yes

Child #3 - First Name

Child #3 - Middle Initial

Child #3 - Last Name

Child #3 - Student?

YesNo

Child #3 - Name of School/Center

Child #3 - Grade

Child # 3 - Check all that apply to child (skip if "no")

Head Star

Yes

Foster Child

Yes

Homeless, Migrant, Runaway

Yes

Child #4 - First Name

Child #4 - Middle Initial

Child #4 - Last Name

Child #4 - Student?

YesNo

Child #4 - Name of School/Center

Child #4 - Grade

Child # 4 - Check all that apply to child (skip if "no")

Head Start

Yes

Foster Child

Yes

Homeless, Migrant, Runaway

Yes

Child #5 - First Name

Child #5 - Middle Initial

Child #5 - Last Name

Child #5 - Student? Y/N

YesNo

Child #5 - Name of School/Center

Child #5 - Grade

Child #5 - Check all that apply to child (skip if "no")

Head Start

Yes

Foster Child

Yes

Homeless, Migrant, Runaway

Yes

STEP 2: Do any Household Members (including you) currently participate in one or more of the following eligible assistance programs: Snap TANF, or FDPIR? If NO > Go to STEP 3.

Check all that apply.

SNAP

Yes

TANF-FEP

Yes

FDPIR

Yes

Enter case number of the selected assistance program in this space. Do NOT put Medicaid number.

STEP 3: Report Income for ALL Household Members (Skip this step if you answered "Yes" to STEP 2)

A. Child Income - Sometimes children in the household earn or receive income. Please include the TOTAL income received by all Household Members listed in STEP 1 here.

How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

B. List all household members not listed in STEP 1 (including yourself) even if they do not receive income. For each person listed who receives income, report total gross income (before taxes) for each source in whole dollars (no cents) only.

If they do not receive income from any source, write "0". If you enter "0" or leae ay fileds blank, you are certifying (promising) that there is no income to report.

Adult # 1 - First and Last Name

Adult # 1 - Earnings From Work

Adult # 1 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult # 1 - Public Assistance/Child Support/Alimony

Adult # 1 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult # 1 - Pensions/Retirement/All Other Income

Adult # 1 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #2- First and Last Name

Adult #2 - Earnings From Work

Adult #2 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #2 - Public Assistance/Child Support/Alimony

Adult #2 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #2 - Pensions/Retirement/All Other Income

Adult #2 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #3 - First and Last Name

Adult #3 - Earnings From Work

Adult #3 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #3 - Public Assistance/Child Support/Alimony

Adult #3 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #3 - Pensions/Retirement/All Other Income

Adult #3 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #4 - First and Last Name

Adult #4 - Earnings From Work

Adult #4 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #4 - Public Assistance/Child Support/Alimony

Adult #4 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #4 - Pensions/Retirement/All Other Income

Adult #4 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #5 - First and Last Name

Adult #5 - Earnings From Work

Adult #5 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #5 - Public Assistance/Child Support/Alimony

Adult #5 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Adult #5 - Pensions/Retirement/All Other Income

Adult #5 - How Often? Weekly, Bi-Weekly, 2x Per Month, Monthly

Total Household Members

Last 4 of SSN

Check if No SSN

√

Signature of Adult filling out the form

Clear

Today's Date

Thank you for filling out the form.

We will get back to you shortly with more information and next steps. Let me know if you want a copy of the completed form for your records and I will email it to you.

Free And Reduced Price Meals Application

2022-2023 Free and Reduced Price Meals

STEP 1: List A household members who are infants, children, and students up to and including grade 12 (if more spaces are needed pleas send an email to erin.arrigo@wasatchwaldorf.org with the additional children's information

Definition of Household Member. Anyone who is living with you and shares income an expenses, even if not related.

Children in Sate Foster Care and children who meet the definition of Homeless, Migrant, Runaway, or participate in Headstart programs are eligible for free meals. Read How to Apply for Free and Reduced Price School Meals for more information.

Child # 1 - Check all that apply to child (skip if "no")

Child # 2 - Check all that apply to child (skip if "no")

Child # 3 - Check all that apply to child (skip if "no")

Child # 4 - Check all that apply to child (skip if "no")

Child #5 - Check all that apply to child (skip if "no")

STEP 2: Do any Household Members (including you) currently participate in one or more of the following eligible assistance programs: Snap TANF, or FDPIR? If NO > Go to STEP 3.

Check all that apply.

STEP 3: Report Income for ALL Household Members (Skip this step if you answered "Yes" to STEP 2)

B. List all household members not listed in STEP 1 (including yourself) even if they do not receive income. For each person listed who receives income, report total gross income (before taxes) for each source in whole dollars (no cents) only.

If they do not receive income from any source, write "0". If you enter "0" or leae ay fileds blank, you are certifying (promising) that there is no income to report.

Thank you for filling out the form.

charts for STEP 3

Our highest endeavor must be to develop free human beings who are able, of themselves, to impart purpose and direction to their lives.