Welcome to The Notre Dame School Thank you for your interest in joining our community. We offer an engaging, quality Catholic education for students from preschool through 8th grade. While facilitating the learning process, our teachers also recognize and support parents in their role as the primary educators of their children. Motivated by faith, our faculty and staff celebrate academic achievement and nurture in students a love of God, a sense of compassion for others, and recognition of the importance of service to others. We are committed to the education of the whole child, incorporating co-curricular activities and learning in a variety of modalities. I encourage you to call us to schedule a tour of campus during the school day -- when our community is most vibrant -- to see the many ways we provide student learning opportunities. Enrollment for the 2020-2021 school year opens February 2019. I encourage you to return the completed application forms to begin the enrollment process. Thank you again for you interest, we look forward to your family becoming part of the Notre Dame Family. In Christ’s name,

Marissa Carroll Principal

2020-2021 Notre Dame School Application

Student Name:____________________________________________________________M___F___

Last First Middle

Date of Birth:____/_____/_____ Birthplace:_____________________

Address:____________________________________________________________________

Street Number & Name City Zip

Name of Guardian #1:_______________________________________________________________

Birthplace:_________________________ Religion:__________________________________

Occupation:________________________ Employer _________________________________

Guardian’s work #:_____________________________ Cell Phone Number:_____________________

Would you like to receive emergency texts (circle one)? Y N

If so, please provide your cell phone company carrier:____________________

Guardian’s Email:_________________________________________________________________

Name of Guardian #2:_______________________________________________________________

Birthplace:_________________________ Religion:__________________________________

Occupation:________________________ Employer _________________________________

Guardian’s work #:_____________________________ Cell Phone Number:_____________________

Would you like to receive emergency texts (circle one)? Y N

If so, please provide your cell phone company carrier:____________________

Guardians’s Email:_________________________________________________________________

Parish Information

Name of Family Parish or Church:______________________________________________________ Date of Baptism:____________ Location:________________________ Date of First Communion:____________ Location:________________________

Educational Background

Previous School(s) child attended : ______________________________________ Grade last completed:______________ Any previous special education plan? ___________________ Please explain any special circumstances we should be aware of:___________________________ _______________________________________________________________________________ Short Answer Questions (Required)

1. Why do you want your child to attend a Catholic parochial school in the Archdiocese of Los Angeles?

2. How much involvement do you hope to have in your child’s homework and academic experience? Are you committed to being the primary educator of your child with our curriculum and teachers as a support to you?

3. What talents, interests, expertise, or job experience do you have that will enrich our community? What talents, interests, or expertise does your student have that will enrich our community?

New Enrollment Checklist  

Included in this packet, you will find the following items. Those with check boxes need to be returned to the School Office by August 18, 2020. 

 ❏ Immunization Records Form ❏ Income Survey ❏ CA Health Examination for Entry to School (incoming K or 7th only) ❏ Baptismal Certificate, Holy Communion Certificate, if have received sacraments ❏ Sacrament Questionnaire ❏ Family Census Survey (Religion, Education, Language, Origin) ❏ Emergency Card ❏ Dismissal Authorization Form ❏ Extended Care Program Questionnaire ❏ Tuition Schedule and Rates ❏ Tuition Contract ❏ CEF Paperwork if applying for Financial Aid (Due by March 20th to NDS) ❏ Birth Certificate ❏ Custody Paperwork (if necessary) ❏ Uniform Guidelines Agreement ❏ Bell Schedule Paperwork ❏ Parent Release for Student or Minor Non Commercial (ADLA) ❏ Technology Agreement ❏ Authorization for Release of Records from Previous School 

 Preschool Only ❏ LIC Form 995 ❏ LIC Form 613A ❏ LIC Form 700 ❏ LIC Form 702 ❏ LIC Form 627 ❏ LIC Form 995E ❏ LIC Form 701 ❏ ND Preschool enrollment questionnaire

 

Authorization For Release of School Records   

  

_______________________________________________________________________________ School student presently attends  

   

_____________________________________ 

_____________________________________ 

School Address 

   

I Hereby authorize the release to the below named school all school records, including grades, health records, and any other developmental information regarding the below named pupil:    

_______________________________________________________________________________ Name of Student  

  

D.O.B ______/______/_______ Grade:___________     

__________________________________________________________ __________ Signature of legal guardian Date 

  

Please send the above requested information to:  

The Notre Dame School  Attn: School Secretary 

33 East Micheltorena Street Santa Barbara, CA 93101  

Ph:(805)965-1033 Fax:(805)965-1034  

Dismissal Authorization Form

Family’s Last Name:______________________________________________ Children’s Names: Grades: _________________________________________ ________________ _________________________________________ ________________

_________________________________________ ________________ _________________________________________ ________________ _________________________________________ ________________ My Child(ren) have permission for the following (if nothing is checked we will assume none are allowed): ______ Walk home ______Take the Bus _____ Ride a bike/skateboard ______Will be picked up by a third party aftercare program.(Girls Inc, PAL, Etc) Name of program________________________________________ Days allowed for pick-up (Circle days): Monday Tuesday Wednesday Thursday Friday If any of this information should change, I will contact the school immediately. _____________________________ _________________ Parent/ Guardian Signature Date

2020-2021 Family Financial Obligations  

Tuition Rates 

1 Child  2 Children  3+ Children 

$5,000  $9,000  $12,000 

 Registration **Due by June 1 for returning families, due at enrollment for new families 

1 Child  2 Children  3+ Children 

$250  $450  $550 

 Fundraising 

Obligation  Short Description  

Jog A Thon  $50 per family - charged in November if not raised by Oct 9 

Auction Donation  $50 - charged in January if not delivered to Office in December 

Raffle Tickets - Auction  15 Tickets per family for Auction. Will charge $50 in March if not sold in Jan/Feb 

Raffle Tickets - Fiesta  50 Tickets per family for Fiesta. Will charge $50 in May if not sold in April. 

 Service Hours 

Opportunities  Family Commitment Opportunities - Description and Examples 

Parent Teacher Guild  Monthly meetings, organizing events, communicating to other parents 

Auction  Committee, pre-auction basket making, night-of assistance, donation solicitation 

Classroom Parent  Bulletin boards, chaperone field trips, spread information, help teacher in class 

Athletics  Drive to and from sporting events, provide snacks and water to players 

Supervision  Recess, Lunch Duty, morning gate, breakfast distribution, crosswalk duty, etc 

Fundraising  Organizing nacho sales, fruit sales, dine-outs for class field trips 

Supplies  Donating supplies for classroom projects when teachers need them 

Fiesta  Committee, pre-fiesta preparation, working booths, day-of assistance 

Movie Nights  Helping out with cooking or selling during movie night 

Cleaning & Maintenance  Summer clean outs of school, hanging paintings, moving heavy items, etc 

Notre Dame School Tuition and Fees Agreement 2020-2021 

 I _________________________________, have read the Notre Dame School Enrollment or Recommitment Packet and agree to pay all the tuition and fees applied towards the 2020-2021 school year. Payments will be made in installments over a period of 11 months. I understand that I have the option of my monthly payments to be withdrawn on either the 5th or the 20th of the month as per the SMART tuition management plan. Payments made in the school office must be made by the 30th or 15th of each month to be applied to SMART on time.  I understand that if I miss a monthly payment due to insufficient funds or any other reason, I will be assessed a missed payment fee by SMART and may incur fees from my own financial institution. If my checking account shows “Insufficient Funds” twice in one School year, I must submit in writing an alternative payment method to Notre Dame school. I understand that by not meeting the financial obligations as scheduled, my child(s) placement for the academic school year is subject to forfeiture.   I further understand my obligations to pay the tuition and fees for the full academic academic year are conditional. In any case where Notre Dame dismisses a student for disciplinary reasons, the tuition for the remainder of that month will not be refunded. Subsequent monthly payments will not be due.  

Initials____________  Financial Assistance - Planned & Unplanned:  I understand that if I choose to apply for financial assistance I am required to apply to the Catholic Education Foundation. I understand that if I do not apply, I will not receive assistance for my family. I am aware that Notre Dame School is restricted in the amount of financial assistance available and that the submission of my application does not guarantee my family’s financial assistance.  

Initials____________   Family Service Hours, School Fees and Raffle Tickets:  I understand that my family is responsible to fulfill its service hours obligation noted at the tuition meeting with Mr. Carroll. If I do not fulfill my service hours commitment or provide service to the community in an alternate way, I may be placing my student’s 2021/2022 enrollment in danger. Parents may choose to pay a $550.00 non-participation buy-out at the beginning of the school year.   

  Initials____________  I understand that all extra fees pertaining to extra-curricular activities such as, but not limited to, after school sports, graduation fees, class field trips, the extended care program, etc. will be applied to my monthly tuition paid though SMART.    

Initials____________  I understand that I am responsible to fundraise a total of $200 for NDS in the form of Auction Item, Auction Raffle Tickets, Festival Raffle Tickets, Jog a Thon Pledges. If I do not fundraise, I will be charged in the month following the due date or can pay $200 up front.        

Initials____________ I further understand that in signing the tuition/ fees contract for the 2020-2021 Academic year, I agree to accept the rules and regulations of the school in their entirety. It is my responsibility to read the school handbook on the school Website, read all notifications sent home including electronic newsletter. 

  Initials____________    ______________________________ ____________________________ ____________________ 

Parent/Guardian Name Printed  Parent/Guardian Signature  Date  

UNIFORM GUIDELINES 2020-2021

A. GENERAL REGULATIONS The wearing of a uniform is an integral part of Catholic school discipline, aiding in good order and concentration on the academic nature of school. Students are less conscious of clothing trends, peer comparisons, and disparity in socio-economic status when in uniform. All students are expected to be in complete uniform beginning the first day of school. Compliance with uniform guidelines can affect conduct grades and repeated infractions will result in a family conference with the Principal.

The Principal is the final arbiter regarding questions of dress code compliance. If a student is out of uniform, the parent will be notified to bring clothing that follows uniform guidelines. Efforts will be made by faculty and staff to observe uniforms not following guidelines followed by a notification to student and parent prior to the start of the school day. Uniforms must be clean, pressed, and mended. Shirts must be tucked in at all times except for PE uniforms. All uniforms are to be purchased from DENNIS Uniform Company https://www.dennisuniform.com/ (School code: SH00ND)

B. DAILY UNIFORM POLICY - MONDAY - THURSDAY Boys 1. Kindergarten – 5th Grade

Navy Blue Pants Cardinal Uniform Polo with Notre Dame logo in short or long sleeve Plain black, brown, or navy blue belt, if a belt is worn. Canvas material is not allowed. Plain white undershirt, if worn Navy Blue uniform sweater or fleece with school logo, if needed Navy Blue jacket with Notre Dame logo for outdoor wear White, black, or navy blue socks SOLID COLOR shoes of navy blue, black, brown, burgundy, or white coloring. Bright colors, large logos, and designs are not permitted. Visible logos must be of the same color as the shoe.

2. 6th - 8th Grade

Navy Blue Pants Cardinal Uniform Polo with Notre Dame logo in short or long sleeve Plain black, brown, or navy belt. Canvas material is not allowed. Plain white undershirt, if worn Navy Blue uniform sweater or fleece with school logo, if needed Navy Blue jacket with Notre Dame logo for outdoor wear White, black, or navy blue socks SOLID COLOR shoes of navy blue, black, brown, burgundy, or white coloring. Bright colors, large logos, and designs are not permitted. Visible logos must be of the same color as the shoe. Casual dress shoes are preferred, but plain canvas shoes in the Vans, Converse style are permitted.

Girls 1. Kindergarten – 4th Grade

Plaid Uniform Jumper, plaid skirt, or skort Modesty shorts under skirt or jumper Cardinal polo in short or long sleeve White under shirt, if worn Navy Blue uniform sweater or fleece with school logo, if needed Navy Blue jacket with Notre Dame logo for outdoor wear White, black, or navy blue ankle or knee high socks Navy Blue tights for warmth, if necessary. If tights are worn, socks are not required. SOLID COLOR shoes of navy blue, black, brown, burgundy, or white coloring. Bright colors, large logos, and designs are not permitted. Visible logos must be of the same color as the shoe. Casual dress shoes are preferred, but plain canvas shoes in the Vans, Converse style are permitted. Heels must not be higher than one inch

Hair accessories must be only uniform plaid, Navy blue, burgundy/red, or yellow. Makeup, nail polish, and dyed hair of non-natural colors are NOT permitted.

2. 5th Grade – 8th Grade

Plaid skirts or skorts no shorter than 2 inches above the middle of the knee Modesty shorts under skirts Cardinal polo in short or long sleeve White under shirt, if worn Navy Blue uniform sweater or fleece with school logo, if needed Navy Blue jacket with Notre Dame logo for outdoor wear White, black, or navy blue ankle or knee high socks Navy Blue tights for warmth, if necessary. If tights are worn, socks are not required. SOLID COLOR shoes of navy blue, black, brown, burgundy, or white coloring. Bright colors, large logos, and designs are not permitted. Visible logos must be of the same color as the shoe. Casual dress shoes are preferred, but plain canvas shoes in the Vans, Converse style are permitted. Heels must not be higher than one inch Makeup, nail polish, and dyed hair of non-natural colors are NOT permitted. One pair of stud earrings, one piece of religious jewelry around neck, on hand, or on wrist is allowed. Watches are permitted.

Cold Weather In times of colder weather: Students may wear only their Notre Dame jackets or sweaters. No other jackets may be worn that is not a Notre Dame issued uniform. Underneath any uniform polo, students may wear a long sleeved white shirt. Turtlenecks are permitted. For girls: Only navy blue tights may be worn underneath their skirts. NO other type of tights can be worn.

C. PHYSICAL EDUCATION UNIFORM - FRIDAYS

Shirt may be Red NDS P.E. Shirt or a Jog a Thon shirt Shorts may be PE Navy Mesh Shorts or Navy Blue uniform shorts. NO logos. Plain shoes of gray, navy blue, black, or white coloring conducive to running and physical fitness

D. FREE DRESS

Girls a. Dresses and skirts must be no shorter than uniform length b. No spaghetti straps/ Bra Straps/ work out gear c. No crop tops or excessive skin d. Must wear sneakers, no boots or flip flops e. No ripped jeans or pants f. No offensive or inappropriate logos ( determined by Pastor and Principal)

Boys: g. Must wear sneakers, no boots or flip flops h. No ripped jeans/ pants i. No offensive or inappropriate logos ( determined by Pastor and Principal)

UNIFORM GUIDELINES AGREEMENT

I , _________________________________________, agree to uphold the uniform guidelines of The Notre Dame School. This is to include purchasing appropriate sized uniforms for my child(ren) so that my child(ren) is in compliance with uniform policies at all times.   I understand that free dress is rare, typically limited to Catholic Schools Week and on the day of my child’s birthday as long as it does not fall on a Mass day.  

Initials _________  I understand that I may be called to bring appropriate and uniform compliant clothes for my child to school if they are found out of uniform.  

Initials _________  I understand that all outerwear, even on the coldest of days, should adhere to NDS uniform guidelines and display an NDS logo at all times.  

Initials _________  I will make every effort to purchase shoes for my child(ren) that adhere to uniform guidelines in color and style. It is my responsibility to ensure my children are not asserting their superiority over other students through the brand or fashion of their shoes.  

Initials _________  I understand that if my son is in grades 6 to 8, they must wear a belt every day except for Fridays when they wear their PE uniform.  

Initials _________  I understand that my daughter can wear bows of any size as long as they are a color in our uniform plaid (yellow, red, navy, or white) or the pattern of the uniform plaid itself.  

Initials _________   ___________________________________ Printed Parent Name   ___________________________________ _________________ Parent Signature Date 

Extended Care Program

Notre Dame’s Extended Care Program is primarily focused on providing students additional support in completing their homework. There is a half hour period where students are provided snack and recess time, with the final half hour of ECP dedicated to students choosing their own indoor activity that can include drawing, puzzles, board games, etc. The 2020-2021 Extended Care rate is $30.00 a month per child with a $60.00 per month maximum per family. Extended Care is Monday, Tuesday, Thursday, and Friday from 3pm - 5pm and on Wednesdays from 1pm to 5pm. If you are interested in having your child attend Extended Care, please provide the following: _____________________________________________________________________________

ECP Expression of Interest

Name of Parent ____________________________________________

Name of Child(ren) _________________________________________

_________________________________________

_________________________________________

Days needing Extended Care Monday Tuesday

Wednesday Thursday

Friday

Expected Daily Pick Up Time _______________

I understand I will be given additional paperwork to provide ECP staff with all necessary information to preserve the safety of my child(ren). Initial _________ I understand that I will need to sign out my child in person each time I pick up. Initial _______ I understand that excessive late pick up will require additional conversations with ECP staff and Principal and it is possible my ECP privilege will be revoked. Initial ________

 

Notre Dame School Acceptable Use Policy  A Notre Dame School graduate is ideally a critical and conceptual thinker who can access, evaluate, and use information for problem solving while efficiently using and adapting to changing technology. The use of technology is an ongoing integral part of Notre Dame School's core curriculum. It is imperative that technological resources be used to build community, encourage critical reflection, foster readiness for high school, and to promote ethical and serious academic use.   This policy serves to define expected standards of behavior by all users of technology within the school. Violations of this policy will result in loss of technology privileges for an extended period of time and disciplinary review within the philosophy and policies of Notre Dame School that may result in detentions, suspensions, or expulsion from school .  Student technology iPads are provided to members of the Notre Dame School community for academic and other school-related work. All accounts and devices are to be used in a manner that respects and protects individual rights as well as the well-being of the school.   The granting of a device for educational use is to be considered a privilege and to be subject to monitoring for appropriate use. Use of any computing resources at Notre Dame School implies agreement with the principles of use outlined in this policy and to monitoring of accounts and devices by network supervisors. Ipads, technological devices, and related systems are designed for academic use in line with policies and schedules established by the administration of the school and the Technology Committee of Notre Dame School.  Please read the Notre Dame School Acceptable Use Policy for Technology in its entirety before indicating your agreement to its terms and conditions. This policy can be found on pages 43-48 in the parent handbook at https://notredamesb.org/handbook.    Student Agreement I have read the ACCEPTABLE USE POLICY FOR TECHNOLOGY for the use of the computer network at Notre Dame School and understand that this access is designed for educational purposes. I agree to abide by the terms of the policy and recognize that failure to comply with these standards will result in disciplinary action.  

Student Name:______________________________ 

Signature:______________________________ 

Date:______________________________ 

 Parent Agreement I have read the ACCEPTABLE USE POLICY FOR TECHNOLOGY for the use of the computer network at Notre Dame, and understand that this access is designed for educational purposes. I recognize that it is impossible for Notre Dame to restrict access to all controversial materials and I will not hold NDS or NDS employees responsible for any such materials acquired on the network by my student. I accept that if my student violates this policy he/she will lose device access and may be subject to further disciplinary action.  Parent Signature:______________________________ 

Full Name:______________________________ 

Date:______________________________ 

ARCHDIOCESE OF LOS ANGELES PARENT/GUARDIAN RELEASE FOR STUDENT OR MINOR 

(NONCOMMERCIAL)  

Name of Location : The Notre Dame School 

The Location intends to use your child’s image, name, voice and/or work for noncommercial purposes relating to the event(s) or activity(ies) identified below.  

Description of events/activities to which this Release applies: Including but not limited to Recess, Lunch, School activities, Classroom activities, Jog a Thon, Mass, Festival, Graduation, First Holy Communion, Catholic Schools Week, and all other activities in which student might be participating that is worthy of sharing 

Duration of Release: 2020 - 2021 School Year (August to June) 

This section to be completed by Parent/Guardian:  

I, __________________________________________________________________________ am the parent/guardian of _________________________________________________________ , a minor.  

I hereby authorize the Location to use the following personal information about my child: (Please initial the applicable boxes)  

Image: 口 yes 口 no   

Voice: 口 yes 口 no  

Name: 口 yes 口 no  

Work : 口 yes 口 no  

I understand and agree that my child’s image, voice, name and/or work (“Personal Information”) relating to the events or activities described                                         above will be used for noncommercial purposes, including, but not limited to, publicity, exhibits, electronic media broadcasts or research. I                                       understand and agree that my child’s Personal Information may be copied, edited and distributed by the Location in publications, catalogues,                                       brochures, books, yearbooks, magazines, exhibits, films, videotapes, CDs, DVDs, email messages, websites, or any other form now known or later                                       developed (“Materials”).  

The Location may use the Personal Information at its sole discretion, with or without my child’s name or with a fictitious name, and with accurate                                                 or fictitious biographical material. The Location will not use the Personal Information for improper purposes or in a manner inconsistent with the                                           teachings of the Roman Catholic Church.  

I waive any right to inspect or approve any Materials that may be created using the Personal Information now and in the future. In exchange for                                                   the opportunity given to my child by the Location to participate in the activity, I agree that neither I, nor my child, will receive monetary                                                 compensation, royalties or credit. I understand and agree that the Location shall be the owner of all right, title and interest, including copyright, in                                               the photographs, electronic recordings and Materials. If the Location intends to use the Materials for a commercial purpose, I will be provided at                                             that time with information about the terms of the commercial use.  

Page 1 of 2 Copyright © 2014 Roman Catholic Archbishop of Los Angeles, a corporation sole. All rights reserved. Revised 2018   

I hereby waive, release and forever discharge any and all claims, demands, or causes of action against the Location and its affiliated entities,                                             employees, agents, contractors and any other person, organization, or entity assisting them with the photography, electronic recording or                                   Materials, for damages or injuries in any way related to, or arising from the photography, electronic recording or Materials, or the use of the                                               Personal Information, and I expressly assume the risk of any resulting injury or damage.  

I further understand and agree that this Authorization remains in effect until it is withdrawn in writing. I understand that if I change my mind                                                 about this Authorization, that I will submit another, new authorization form to the Location. However, my new authorization will not have the                                           effect of revoking this Authorization, and the Location will have no duty or obligation to make any changes or alterations to any Materials that                                               may have been prepared based on this Authorization.  

I represent that I have read this Authorization, understand the contents and am able to grant the rights and waivers it contains. I understand that                                                 the terms of this Authorization are contractual and not mere recitals. I am signing this document freely and voluntarily.  

Signature: _________________________________________________________ Date: ________________________________  

Print Name: ___________________________________________ Relationship to Child: __________________________  

Address: ___________________________________________________________________________________________________  

Telephone: ___________________________ Cellphone: _____________________________  

Email: ______________________________________________________________________________________________________  

Name of Child: ______________________________________________________________ Age: ________________________  

 

 

 

 

 

 

 

 

 

 

Page 2 of 2 Copyright © 2014 Roman Catholic Archbishop of Los Angeles, a corporation sole. All rights reserved. Revised 2018

  

Sacrament Questionnaire  

Date _______________ 

 

Has your child been baptized in the Catholic faith? 

Yes______ No________ 

If so, at what Parish? _________________________________________________ 

Has your child been baptized in any faith?  

Yes______ No________ 

What faith? _____________________________________________ 

If your child has not been Baptized, would you like to have him/her Baptized in the Catholic faith?  

Yes_______ No______ 

Has your child received the Sacrament of First Holy Communion? 

Yes_______ No______ 

 

If your child is over the age of 7 and has not received the Sacrament of Baptism or Sacrament of First 

Holy Communion, would you like to have him/her prepared through the Rite of Christian Initiation 

for Children to receive his/her sacraments?  

Yes_______ No_______ 

CENSUS DATA 2020-2021 This information is to fill out various census surveys to the Archdiocese of Los Angeles and the State of California throughout the

school year. Please do not leave any identifying information on this form. This information must be filled out each year.

Religion (check one) ❏ Roman Catholic ❏ Christian (Denomination _______________________________________) ❏ Jewish ❏ Buddhist ❏ Hindu ❏ Other _______________________________________

Parish where you attend Mass if you are Roman Catholic

Name of Parish ____________________________________________

City _____________________________________________________

How often is English spoken in your home?

❏ English is ALWAYS spoken ❏ English is MOSTLY spoken ❏ English is SOMETIMES spoken ❏ English is RARELY spoken ❏ English is NEVER spoken

If English is spoken Mostly, Sometimes, Rarely, or Never, what language is spoken?

❏ Spanish ❏ Other __________________________________

Does at least one adult over 18 in the household read, write, or speak English? ❏ Yes, read ❏ Yes, write ❏ Yes, speak ❏ Yes, read, write, and speak ❏ No

What is the highest earned level of education in the household, either in the United States or abroad?

❏ High School Diploma ❏ Associate Degree (2 year undergraduate degree) ❏ Bachelor’s degree (4 year undergraduate degree) ❏ Masters Degree (graduate degree) ❏ Doctorate Degree (PhD, MD, JD degree) ❏ None of these

Have any of the children in your household who attend school at NDS come from another country within the past 3 years and be considered an immigrant? ❏ Yes ❏ No

If yes, which country? _____________________________________ If yes, how many children? _________

Do NOT include Family Name or family identifying information on this Sheet

Family Address __________________________________________________

________________________________________________

HOUSEHOLD is defined as all persons, including parents, children, grandparents, and all people related or unrelated who live in your home and share living expenses. If you’re applying for a household with a foster child, you may include the foster child in the total household size.

How many people are in your household? __________

HOUSEHOLD INCOME is considered to be any taxable income each household member received before taxes. This includes wages, social security, pension, unemployment, welfare, child support, alimony, and any other cash income. If including a foster child as part of the household, you must also include the foster child’s personal income. Do not count foster payments as income

What is your family's annual income? ____________________

Using the information above, place a check mark in the following box where appropriate

Income Chart Effective from July 1, 2019 through June 30, 2020

Household Size

Your Income is

MORE THAN the

income

Your income is

LESS THAN the

income

How Often Payment is Received

Annual

Monthly

Twice Per

Month

Every Two

Weeks

Weekly

1 $23,107 $1,926 $963 $889 $445

2 $31,284 $2,607 $1,304 $1,204 $602

3 $39,461 $3,289 $1,645 $1,518 $759

4 $47,638 $3,970 $1,985 $1,833 $917

5 $55,815 $4,652 $2,326 $2,147 $1,074

6 $63,992 $5,333 $2,667 $2,462 $1,231

7 $72,169 $6,015 $3,008 $2,776 $1,388

8 $80,346 $6,696 $3,348 $3,091 $1,546

Each Additio

nal

$8,177

$682

$341

$315

$158

Household does not qualify – income is higher than these numbers per household size

Part 2. SIGNATURE: I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get state and federal funds based on the information I give. I understand that school officials may verify (check) this information. I understand if I purposely give false information that I may be prosecuted.

I understand my child’s poverty status may be shared with other programs/agencies as allowed by law.

Signature: ________________________________________

Date: __________________________________