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School Fees Waiver Application

All information provided in connection with this application will be kept confidential. To apply for fee waiver assistance for your child(ren), please complete this form for each school your children attend. If you have more than one child in a particular school, you may list all the children in that school on one application.

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Child Information *
 Name (First & Last)School & GradeStudent ID
Child 1
Child 2
Child 3
Child 4
Type of Waiver Desired *
Please check if the student or the student's family meets the financial eligibility criteria or is involved in one of the following programs
Please list the names of all wage earners in your household and record the gross monthly income before deductions for taxes, social security, etc. of each wage earner in the household. You are requested to provide documentation that substantiates your household income.
 Name (First & Last)Gross Monthly Income
Person 1
Person 2
Person 3
Your signature below is required for the release of information regarding the student or the student's family financial eligibility for the program checked on this form.  
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NON-DISCRIMINATION STATEMENT

The Sioux City Community School District offers career and technical programs in the following areas: Business & Marketing, Family & Consumer Science, Health Science, and Industrial Arts, Technology, & PLTW.

The Sioux City Community School District is an equal opportunity/affirmative action employer and does not discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, genetic information (for employment), national origin, religion, age (for employment), disability, socioeconomic status (for programs), marital status (for programs), or veteran status (for employment) in its educational programs and its employment practices. The District is required by Title IX and 34 CFR Part 106 not to discriminate on the basis of sex in its programs, activities, or employment.

Inquiries or grievances under Section 504 and Title II of the Americans with Disabilities Act may be directed to Jen Gomez, Director of Student Services & Equity Education/Title IX Coordinator at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, gomezj2@live.siouxcityschools.com. Inquiries about the application of Title IX and its regulations to the District may be referred to the Title IX Coordinator, the Assistant Secretary of the U.S. Department of Education, or both. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.