Waiver of Confidentiality
June 01, 2008
Dear Parent/Guardian:
You do not have to send in this form to get reduced price or free Child Nutrition Program benefits for your children.
To save you time and effort, information about your children’s eligibility for reduced price or free Child Nutrition Program benefitsmay be shared with other programs for which your children may qualify. For the programs listed below, we must have your permission to share your information.
No, I DO NOT want information about my children’s eligibility for Child Nutrition Program benefits shared with any of these programs.
Yes, I DO want school officials to share information about my children’s eligibility for Child Nutrition Program benefits with the programs I have checked below.
Textbooks
If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the programs you checked.
Student: Grade:
Student: Grade:
Student: Grade:
Student: Grade:
Parent/Guardian
Signature (print and sign):
__________________________________________ Date:
Printed Name:______________________________
Address:___________________________________
For more information, you may call:
School Official’s Name: Carol McKenna Phone: 620-672-4500
Return this form to the address below by .
Address: 401 N. Ninnescah, Pratt, KS 67124
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.
