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PERRY CENTRAL COMMUNITY SCHOOL CORPORATION18677 Old State Road 37Leopold, Indiana 47551
Central Office (812) 843-5576Fax (812) 843-4746www.pccs.k12.in.us
High School Office: 812-843-5121 High School Fax: 812-843-4198
Elementary Office: 812-843-5122Elementary Fax: 812-843-5242
2018-2019 NewsletterBack to School Cookout
2018-2019 School CalendarSchool Supply List
7th Grade OrientationElementary News
Preschool InformationBook Rental
Cafeteria NewsAugust Menus
Health Office Info & FormsTitle I Right to Know
Free/Reduced Meal Application
School Begins Tuesday, August 7, 2018 for all K-12 students
Preschool will begin onWednesday, August 8, 2018 for Wednesday/Thursday students
Monday, August 13 for Monday/Tuesday students
Perry Central Family Outreach
August 6 - First Teacher DayS M T W T F S S M T W T F S August 7 - First Student Day
1 2 3 4 1 August 8 - First Day W/Th Preschool5 6 7 8 9 10 11 2 NS 4 5 6 7 8 August 13 - First Day M/T Preschool
12 13 14 15 16 17 18 9 10 11 12 13 14 15 September 3 - Labor Day (NS)19 20 21 22 23 24 25 16 17 18 19 20 21 22
26 27 28 29 30 31 23 24 25 26 27 28 29
30
October 5 - End of Quarter 1S M T W T F S S M T W T F S October 15-19 - Fall Break (NS)
1 2 3 4 5 6 1 2 3 November 21-23 - Thanksgiving7 8 9 10 11 12 13 4 5 6 7 8 9 10 Break (NS)
14 NS NS NS NS NS 20 11 12 13 14 15 16 17
21 22 23 24 25 26 27 18 19 20 NS NS NS 24
28 29 30 31 25 26 27 28 29 30
December 21 - End of Quarter 2S M T W T F S S M T W T F S Dec 24-Jan 1 - Winter Break (NS)
1 NS MU 3 4 5 January 2 - Winter Break (NS/MU)2 3 4 5 6 7 8 6 7 8 9 10 11 12 January 21 - MLK Day (NS/MU)9 10 11 12 13 14 15 13 14 15 16 17 18 19
16 17 18 19 20 21 22 20 MU 22 23 24 25 26
23 NS NS NS NS NS 29 27 28 29 30 31
30 NS
February 18 - President's Day (NS/MU)S M T W T F S S M T W T F S March 8 - End of Quarter 3
1 2 1 2 March 18-22 - Spring Break (NS)3 4 5 6 7 8 9 3 4 5 6 7 8 9
10 11 12 13 14 15 16 10 11 12 13 14 15 16
17 MU 19 20 21 22 23 17 NS NS NS NS NS 23
24 25 26 27 28 24 25 26 27 28 29 30
31
April 19 - Good Friday (NS)S M T W T F S S M T W T F S April 22 - Easter Monday (NS/MU)
1 2 3 4 5 6 1 2 3 4 May 21 - Last Day Students7 8 9 10 11 12 13 5 6 7 8 9 10 11 May 22 - Last Day Teachers
14 15 16 17 18 NS 20 12 13 14 15 16 17 18 May 26 - Tentative Grad. Date21 MU 23 24 25 26 27 19 20 21 MU MU MU 25 May 27 - Memorial Day (NS)28 29 30 26 NS MU MU MU MU
Make Up Days: January 2, January 21, February 18, April 22, May 22, May 23, May 24 NS = No SchoolMay 28, May 29, May 30, May 31 Yellow Highlight MU = Make-Up Day
Blue Highlight = End of QuarterOrange Highlight = HS Mid Term Dates
Perry Central Commodores - www.pccs.k12.in.us
FEBRUARY MARCH
APRIL MAY
Perry Central Schools
JANUARY
2018-2019 Calendar
AUGUST SEPTEMBER
OCTOBER NOVEMBER
DECEMBER
PRESCHOOL GRADE FOUR1 Tri-fold Mat for naps Backpack with Laptop Compartment1 Standard Size Backpack w/room for folder 2 Large Boxes of Tissues1 Large Box of Tissues Colored Pencils OR Box of Crayons1 Box Dry Erase Markers Pencil Box or PouchBoys: 1 Box Gallon Size Heavy-Duty Slider Ziploc Bags 1 Dozen PencilsGirls: 1 Box Quart Size Heavy-Duty Slider Ziploc Bags 3 Pkgs. Expo Brand Dry Erase Markers
ScissorsKINDERGARTEN Earbuds or Headphones (Durable)Backpack (no wheels) Boys: Quart size Ziploc Bags2 Large Boxes of Tissues Girls: 1 Bottle of Germ-X4 Glue Sticks1 Dozen Pencils GRADE FIVE1 Bottle of Germ-X Backpack with Laptop Compartment1 Pair of Headphones (No Earbuds) Headphones or EarbudsBoys: 2 pkgs. Black Expo Dry Erase Markers 2 Boxes of #2 PencilsBoys: 1 Box Quart Size Heavy-Duty Slider Ziploc Bags Colored PencilsGirls: 2 pkgs. Color Expo Dry Erase Markers ScissorsGirls: 1 Box Gallon Size Heavy-Duty Slider Ziploc Bags 2 Boxes of Tissues
1 Glue StickGRADE ONE Art Box Backpack (no wheels) 2 pkgs. Expo Brand Dry Erase Markers2 Large Boxes of Tissues Highlighters8 Glue Sticks Boys: Disinfectant WipesScissors (Fiskars round edge) Girls: 12 oz. Bottle of Germ-X12 oz. Bottle of Germ-XArt Box (No Pouches) GRADE SIXBoys: Crayola Washable Markers Backpack with Laptop Compartment Boys: Quart size Ziploc Bags 2 dozen #2 Pencils Girls: Colored Pencils Colored PencilsGirls: Gallon size Ziploc Bags 1 - 4 pack of Dry Erase MarkersNO SMALL PENCIL SHARPENERS OR NOTEBOOKS Supply Box/Bag
Glue StickGRADE TWO 2 Large Boxes of TissuesScissors Headphones or Earbuds2 Glue Sticks 1-Lg. Spiral Notebook Crayons 1" Binder2 Large Boxes of Tissues Scissors2 Dozen #2 Pencils (no large pencils) Boys: Disinfectant Wipes2 Pink Erasers Girls: 12 oz. Bottle of Germ-XSmall Box for Supplies2 pkgs. Dry Erase Markers (Expo Brand Only) GRADES 7 - 1212 oz. Bottle of Germ-X Bring basic items the first day, such as paper,Earbuds or Headphones pencils and/or pens. Individual teachers may
suggest other items as needed.GRADE THREE1 Dozen #2 Pencils + 2 Dozen for Pencil BankScissors2 Glue Sticks2 Large Boxes of TissuesSmall Box/Pouch for Supplies (no larger than 8"x6")1 Pair of Headphones (No Earbuds)2 Highlighters2 pkgs. Dry Erase Markers (Expo Brand Only)24 Count Crayola CrayonsBoys: Large Container of Disinfectant WipesGirls: 12 oz. Bottle of Germ-X
Perry Central Elementary School ~ 2018-2019 School Supply List
Families that qualify for Free/Reduced Lunches can receive school supply assistance through Perry Central's school supply bank.
7TH GRADE ORIENTATIONAll incoming 7th graders
along with their parents are invited to attend 7th grade
Orientation
WednesdayAugust 1, 2018
Students will learn about new graduation requirements, Perry Central Career Pathways, 21st Century Scholarship
information along with getting a copy of their 7th grade schedule. Students will also have the opportunity to tour the junior/senior high school building,
meet teachers and practice opening their lockers.
A light supper will begin at 5:30 p.m. with the program starting at 6:00 p.m. in the Cafetorium.
If you have any questions or for more information please email Mrs. French jfrench@pccs.k12.in.us
The following are a few reminders we would like to share with parents and students concerning the operation of the school day.
ALL ELEMENTARY STUDENTS MUST WEAR CLOSED-TOED SHOES.
From time to time we have students who arrive at school before the start of the regular school day. We have worked with parents and students in the past whenever the need for early drop off has arisen and we will continue to do so this year. All students who arrive between 7:00- 7:45 AM are expected to report to the dome.
All students, upon entering the opening day of school, must have immunizations complete and a birth certificate on file in the elementary office.
Students have toys, cell phones, and other personal items that they wish to bring to school. We are asking that parents monitor what students are placing in pockets and backpacks. We cannot be responsible for items that students may bring to school. The best prevention for loss and/or theft is to leave the item at home. Cell phones must be off and out of sight during the school day.
Parents play a key role in the education of their children. By working together we can ensure that all children reach their potential. As questions or problems arise, do not hesitate to ask for a parent-teacher conference. Our goal is to provide a safe, fun, and enriching environment for all students. We know that communication between home and school is essential to the learning process and growth of children. Lights-On After School Program: Dixie Dickerson serves as the director for our after school program that is available every school day until 6:00 PM, except on days when school is dismissed due to inclement weather. Lights On is available to all students enrolled in the elementary, grades preschool to sixth, and is free of charge. Students will be provided a snack, can participate in a variety of workshops that range from fitness to the arts. There will be a schedule on the Lights On door. Tutoring is also available. The program is always in need of volunteers, so please contact Dixie Dickerson if you want to get involved. Stop by the Lights On table during the Back to School Picnic for more information. Look for information early in the school year about evening transportation that will leave Perry Central at 5:30 Monday – Thursday with drop off points within our school district.
PRESCHOOL INFORMATIONPerry Central is proud to provide a preschool for our children and is continually
striving to enhance the program.
Preschool will begin onWednesday, August 8, 2018 for Wednesday/Thursday students
Monday, August 13, 2018 for Monday/Tuesday students
EnrollmentPreschool enrollment and orientation was held in April. Children who are four by August 1st are eligible to attend. There are two class sessions: Monday/Tuesday and Wednesday/Thursday. Class assignments will be available at the Back to School Cookout. All efforts will be made to honor family requests for specific days of class. If enrollment is full, students will be placed on a waiting list. All efforts will be made to enroll interested students, but because this is not a tax-funded program we cannot guarantee enrollment.
Preschool Participation FeesThe fee schedule for preschool is as follows: Daily rate: $10/day Reduced rate: $6/day for students qualifying for free or reduced lunchPreschool fees are billed at the end of each school week, based on the number of days your child attended and the fees are due the following week. Please remember that Perry Central’s Preschool is a self-supporting program which means that your child’s preschool fees pay for all expenses incurred with your child’s educational experience at Perry Central’s Preschool. Timely payments must be made to allow your child to remain enrolled in this self-supporting preschool program.
Preschool Lunch & Snack Fees• The snack and supply fee is $25.00 for the school year.• Lunch payments must be paid by a separate check from snack & supply fees.
Miscellaneous Information• Snack & Supply Fees and Lunch payments may be paid during the scheduled times for book rental sales.• Student nametags may be picked up at the Back to School Cookout. • Please refer to the School Supply List for a list of supplies your child will need for Preschool. Items need to be received on or before the first day of preschool. We encourage you to bring them with you to the Back to School Cookout. All other supplies will be furnished. • Bus drivers will contact families for pick-up times. Please call school if you have questions about your bus route or any other questions.
BOOK RENTAL
Payment for books or arrangements to pay must be made before the first day of school. All past due accounts must be paid in full before arrangements can be made to pay your 2018-2019 book rental.
***********************************
Book rental will be collected in the HIGH SCHOOL COMMONS AREA at the following times. If you cannot come during these times, we suggest you send your check or money order to the school by mail or pay online.
Thursday, August 2 ---------------- 8:00 AM to 7:00 PM Friday, August 3 ---------------- 8:00 AM to 2:00 PM
Due to a ruling by the State Board of Accounts, all checks or money orders must be written for the exact amount of book rental or lunches. Payroll checks cannot be cashed and used for payment.
***********************************
2018 - 2019 Book Rental Prices
Kindergarten ----------$80.00 Grade Four ----------$88.00Grade One -------------$53.00 Grade Five -----------$90.00Grade Two -------------$95.00 Grade Six -------------$99.00Grade Three -----------$91.00
CAFETERIA NEWSThe Perry Central Café offers a variety of healthy options for students each school day.
CAFETERIA CHARGING POLICY
The State Board of Accounts will not allow students to charge for school meals. Meal accounts for students need to have a positive balance at all times. (Think of them as a debit card, not a credit card.) Federal guidelines and our policy allow for a maximum of a $5 negative balance to allow for timing issues. Please do not think we are being insensitive, but state and federal guidelines have brought us to this point. At the same time, we want to make sure that every child has something healthy to eat each day.
If your child has a debt, please pay the account off in full or send his/her lunch to school each day. We will not deny students food, so we will have an option available for students who have a negative balance. (Most likely this will be a peanut butter/jelly sandwich.)
(Continued on next page)
LUNCH PAYMENTSAll students in grades PK-12 will need to have money in their lunch account prior to the first day of school. For your convenience, lunch payments can be paid online via Skyward, or a check can be mailed or brought to school during book rental. However, lunch money cannot be included on the same check as book rental.
If you cannot pay for lunches before the first day of school, we suggest that you send the appropriate amount of money with your child for his or her meals on the first day.
Skyward Log-In: Skyward is our student information system, which provides “one-stop shopping” for parents, students, and staff. Parents can check grades, discipline records, and attendance; communicate with teachers; make credit card payments; and much more. There is a quick link to Skyward on the homepage of our website. If you need to update your email address or if you need additional assistance, please call our office at 812-843-5576 or email techsupport@pccommodores.org.
No Change at Lunch LineBeginning in the 2018-2019 school year there will be no change given in the lunch line. This is to speed up the line and to avoid errors. Students can have exact change for à la carte purchases or the overage will be applied to their lunch account.
CAFETERIA NEWS
LUNCH OPTIONS
Lunch is offered daily in the cafeteria between 10:45 AM-1:30 PM. • Pre-School – 2nd grade: Type A Lunch Tray • 3rd – 4th grade: Type A Lunch Tray or Salad Tray • 5th – 12th grade: Type A Lunch Tray or Sub Tray or Salad Tray or Soup & Sandwich Tray o Healthy Chips will be available for purchase for $1.00 for 5th-12th graders. o 5th/6th grade students must pay for chip purchases as they go through the lunch line. o 7th-12th grade may charge chips to their lunch account as long as they have money in their lunch account.
FREE/REDUCED LUNCH APPLICATIONS Our goal is to help any qualifying family utilize federally subsidized meals for their children. If you think you may qualify, we hope you will apply. To make the process more convenient, we are moving to an on-line application process. Paper applications will still be accepted and can be found on our website, or we will send you one if you call 812-843-5576.
To apply on-line: • From the Perry Central website – www.pccs.k12.in.us • Click on the Skyward link and log-in. • Click on the Food Service tab on the left side of the page. • Click on the Application button on the top right of the page. • From the Application page, click “Add Application”. • Read and follow the directions using the NEXT button to go through the application packet.
CAFETERIA FEES
• Lunch for all students Pre-School - 12th grade will be $2.55. • The cost for breakfast for students is $1.25. • Reduced price is 40¢ for lunch and 30¢ for breakfast.
BREAKFASTBreakfast is offered daily. Students that qualify for Free/Reduced are eligible for a breakfast tray. Elementary students in grades Pre-School-6th will be served breakfast from 7:45 AM-8:30AM in the cafeteria. Jr./Sr. High students in grades 7-12 may purchase breakfast in the High School Commons Area from 7:30 AM-8:00 AM.
Understanding the Lunch Line: A Parent’s Guide
Each day, your child is offered a lunch containing the following:
Meat or Meat Alternate, Grain,
Fruit, Vegetable
and of course, Milk!
While the most nutritious lunch contains all of these options, we understand that sometimes our students do not like some of the
items we serve. To make our student customers happy, we like to give them the option to decline
items they do not want to eat.
Out of the 5 food groups your student is offered, he must choose at least 3 food groups for his meal. One of the food groups must be a fruit or vegetable. Some of the menu choices may count as two food groups
such as pizza, nachos, cheeseburger, or chef salad!
Here’s an example menu: Cheeseburger on a Bun
1/2 cup Carrots 1/2 cup French Fries
1/2 cup Peaches 8oz of Milk
So, your child could choose: Cheeseburger on a Bun and Fries
Carrots, Peaches and Milk
Cheeseburger on Bun, Peaches and Milk
Of course they can take other combinations or all 5 food groups!
The choice is up to them!
If your child comes home and says she didn’t get enough to eat at lunch, ask if she is taking all of her fruit and vegetable choices!
Don’t forget about breakfast! Join us each morning, breakfast is a great way
to kick off your child’s day!
Breakfast choices are a little different. Students must take at least 3 of the
offered items at breakfast, one must be a fruit or vegetable.
This institution is an equal opportunity provider.
Monday Sausage & Egg Biscuit Sandwich
Tuesday Blueberry Muffin with Sausage
Wednesday French Toast Sticks
Thursday Breakfast Pizza
Friday Biscuit & Gravy with Sausage
This institution is an equal opportunity provider.
Breakfast is offered daily in the Cafeteria from 7:45-8:30 AM.
Elementary (Preschool - 6th Grade) Menu
A choice of cereal is offered each day.Milk, juice, and fruit are served daily with breakfast.
The menu below will repeat weekly.
Monday Sausage & Egg Biscuit Sandwich
Tuesday Blueberry Muffin with Sausage
Wednesday French Toast Sticks with Sausage
Thursday Breakfast Pizza
Friday Biscuit & Gravy with Sausage
A choice of cereal is offered each day.
This institution is an equal opportunity provider.
Breakfast is offered daily in the HS Commons Area from 7:30-8:00 AM.
High School (Grades 7-12) Menu
Parfaits offered each day.
Milk, juice, and fruit are served daily with breakfast.
The menu below will repeat weekly.
6
Corn Dog Baked Beans
Peaches
7
PizzaburgerCorn
Mixed FruitChocolate Chip Cookie
8
BurritoCooked Broccoli
Pineapple
9
PizzaFrench FriesApplesauce
10
Taco SaladCornPears
13
Hamburger on BunBaked Potato Half
Cole SlawPeaches
14
Chicken & DumplingsGreen Beans
RollApplesauce
15
Chicken Patty on BunBaked BeansMixed Fruit
16
Bosco SticksFrench Fries
Marinara SaucePineapple
17
SpaghettiCorn
BreadstickPears
20
BBQ Rib Patty on BunCooked Carrots
Peaches
21
Salisbury SteakMashed Potatoes
Gravy / RollGreen BeansApplesauce
22
Pork Patty on Bun Mixed Vegetables
Pineapple
23
Mexican BowlPeas
Mixed FruitChocolate Pudding
24
County Fried Steak Sand.Mashed Potatoes
GravyGreen Beans
Pears
27
Fish NuggetsPeas
Pasta SaladPeaches
28
LasagnaCorn
Garlic BiscuitMixed Fruit
Chocolate Chip Cookie
29
Chicken Noodle SoupGrilled Cheese or
Peanut Butter Sand.Applesauce
30
Pizza French FriesPineapple
31
August Lunch Menu
Birthday treat for all K-6th graders
Peanut butter & jelly sandwiches are offered each day.Milk and fruit are served with lunch entrée.
Carrots, broccoli, celery sticks, and cauliflower are offered daily.Fresh fruits offered daily.
This institution is an equal opportunity provider.
Grades 3 & 4 will have an additional choice of the salad bar DAILY.Grades 5 - 12 will have an additional choice of a sub entrée, soup & sandwich entrée, or the salad bar DAILY.
Monday Tuesday Wednesday Thursday Friday
Health Office Information and NoticesSchool Nurse: Susan Huber | 812-843-5121, extension 135 | shuber@pccs.k12.in.us
2018-2019 School Year School Entry Immunization RequirementsBelow are the number of doses and each vaccine required for school entry. The school nurse asks that you begin making arrangements to have your child immunized at your earliest convenience. This can be arranged with Perry County Hospital at the shot clinic for students with insurance. Uninsured students and students with Medicaid may continue to go to the Perry County health department.
School Immunization Reporting: Perry Central will be participating in the CHIRP system. Parents will be asked to give their consent electronically in Skyward upon enrollment. This will be a one time acknowledgment.
3 to 5 years old
3 Hep B (Hepatitis B)4 DTaP (Diphtheria, Tetanus & Pertussis)3 Polio (Inactivated Polio)1 MMR (Measles, Mumps & Rubella)1 Varicella
K-3rd grade3 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 2 Hep A (Hepatitis A)
Grades 4 to 53 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 2 Hep A*
Grades 6 to 113 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 1 Tdap (Tetanus & Pertussis)2 Hep A* 1 MCV4 (Meningococcal)
Grade 12
3 Hep B 2 MMR5 DTaP 2 Varicella4 Polio 1 Tdap (Tetanus & Pertussis)2 Hep A* 2 MCV4 (Meningococcal) 2 MenB (Meningococcal B)**
Hep B The minimum age for the 3rd dose of Hepatitis B is 24 weeks of age.
DTaP Four doses of DTaP/DTP/DT are acceptable if the 4th dose was administered on or after child’s 4th birthday.
Polio Three doses of Polio are acceptable for all grade levels if the third dose was given on or after the child’s 4th birthday and at least 6 months after the previous dose with only one type of vaccine used (all OPV or all IPV.) For students in grades kindergarten through 7th grade, the final dose must be administered on or after the 4th birthday, and be administered at least 6 months after the previous dose.
Varicella Physician documentation of disease history, including month and year, is proof of immunity for children entering preschool through 9th grade. Parental report of disease history is acceptable for grades 10-12.
MCV4 Individuals who receive dose 1 after their 16th birthday only need 1 dose of MCV4.
Hep A The minimum interval between 1st and 2nd dose is 6 calendar months. K-3 is required.*For grades 4-12, two doses of Hep A are recommended.
MenB **Two doses of Meningococcal Serogroup B vaccine are recommended for Grade 12.
Annual Permission Form To Administer Specific Medications
I request that school personnel administer the medication(s) and its dosage that is checked below to my child while he/she is in attendance at school. Please note any special instructions below. I also request that any prescription medication sent to school be given in accordance with the written instructions from the physician.
STUDENT’S NAME____________________
____Tylenol/Acetaminophen (Non-aspirin) tabs as needed
_____500mg (1tab) _____1000mg (2tab) _____other ________________
____Ibuprofen (Advil/Motrin) tabs
_____200mg _____400mg _____other_________________
Any other Medication and Dosage: _______________________________________________________________________________________________________________
Parent/Guardian__________________________________Date_____________
All medication must be in original containers or they cannot be administered by school personnel.
August 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
September 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
October 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
November 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
February 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
March 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
April 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
May 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Administering personnel signature/initials ________________________ ________________________ Day initialed when medication given
Perry Central Community School Corporation | Leopold, Indiana 47551
Medication: If your child needs to have medication administered at school, please complete the permission form. This can also be used for permission to administer Tylenol, Advil or other over the counter medications as needed. School personnel cannot administer medication un-less it is in its original container and permission is given by parents. If you think your child will require Tylenol or Ibuprofen at school, a bottle needs to be provided. All medications will be destroyed at end of school year if not picked up from nurse’s office by the parent or student in grades 9-12.
PERRY CENTRAL WILL NOT KEEP BULK SUPPLY OF TYLENOL OR IBUPROFEN THIS SCHOOL YEAR.
Perry Central Community School Corporation 18677 Old State Road 37
Leopold, IN 47551 (812) 843-5576
FAX (812) 843-4746 Mary Roberson, Superintendent
July 1, 2018 Dear Parents and Guardians: In accordance with the Elementary and Secondary Education Act, Section 1111(h)(6) PARENTS' RIGHT TO KNOW, this is a notification from Perry Central Community School Corporation to every parent of a student in a Title I school that you have the right to request and receive information in a timely manner regarding the professional qualifications of your student's classroom teachers. This information regarding the professional qualifications of your student's classroom teachers shall include the following: • If the teacher has met state qualification and licensing criteria for the grade level and subject areas taught; • If the teacher is teaching under emergency or temporary status in which Indiana qualifications and licensing criteria are waived; • The teachers baccalaureate degree major, graduate certification, and field of discipline; and • Whether the student is provided services by paraprofessionals, and if so, their qualifications If at any time your student has been taught for 4 or more consecutive weeks by a teacher that is not highly qualified, you will be notified by the school of this information. If you have questions or concerns, please feel free to contact Jennifer Mitchell, Perry Central Elementary Principal at 812-843-5122, or me at 812-843-5576. Sincerely,
Mary Roberson Superintendent
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lls a
t or b
elow
the
limits
on
this
char
t.
2.
HOW
DO
I KN
OW
IF M
Y CH
ILDR
EN Q
UALI
FY A
S HO
MEL
ESS,
MIG
RAN
T, O
R RU
NAW
AY?
Do th
e m
embe
rs o
f you
r hou
seho
ld la
ck a
per
man
ent a
ddre
ss?
Are
you
stay
ing
toge
ther
in a
shel
ter,
hote
l, or
oth
er te
mpo
rary
hou
sing
arra
ngem
ent?
Doe
s you
r fam
ily re
loca
te o
n a
seas
onal
bas
is? A
re a
ny ch
ildre
n liv
ing
with
you
who
hav
e ch
osen
to
leav
e th
eir p
rior f
amily
or h
ouse
hold
? If
you
belie
ve ch
ildre
n in
you
r hou
seho
ld m
eet t
hese
des
crip
tions
and
hav
en’t
been
told
you
r chi
ldre
n w
ill g
et fr
ee m
eals,
ple
ase
call
or e
-mai
l Tar
a Bi
shop
, Ass
istan
t Sup
erin
tend
ent,
at 8
12-8
43-5
576
or tb
ishop
@pc
cs.k
12.in
.us.
3.
DO
I NE
ED T
O F
ILL O
UT
AN A
PPLI
CATI
ON
FOR
EACH
CHI
LD?
No.
Use
one
Fre
e an
d Re
duce
d Pr
ice S
choo
l Mea
ls Ap
plica
tion
for a
ll st
uden
ts in
you
r hou
seho
ld. W
e ca
nnot
ap
prov
e an
app
licat
ion
that
is n
ot co
mpl
ete,
so b
e su
re to
fill
out a
ll re
quire
d in
form
atio
n. R
etur
n th
e co
mpl
eted
app
licat
ion
to: P
erry
Cen
tral
Com
mun
ity S
choo
l Co
rpor
atio
n, A
tten
tion:
Lor
a Hu
bert
, ECA
Tre
asur
er, 1
8677
Old
Sta
te R
oad
37, L
eopo
ld, I
N 4
7551
. 4.
SH
OUL
D I F
ILL O
UT A
N AP
PLIC
ATIO
N IF
I RE
CEIV
ED A
LETT
ER T
HIS
SCHO
OL Y
EAR
SAYI
NG
MY
CHIL
DREN
ARE
ALR
EADY
APP
ROVE
D FO
R FR
EE M
EALS
? N
o, b
ut p
leas
e re
ad
the
lett
er y
ou g
ot ca
refu
lly a
nd fo
llow
the
inst
ruct
ions
. If a
ny ch
ildre
n in
you
r hou
seho
ld w
ere
miss
ing
from
you
r elig
ibili
ty n
otifi
catio
n, co
ntac
t Lor
a Hu
bert
, ECA
Tr
easu
rer,
1867
7 O
ld S
tate
Roa
d 37
, Leo
pold
, IN
475
51, o
r by
phon
e at
(812
) 843
-557
6 or
by
emai
l at l
hube
rt@
pccs
.k12
.in.u
s im
med
iate
ly.
5.
CAN
I APP
LY O
NLIN
E? Y
es! Y
ou a
re e
ncou
rage
d to
com
plet
e an
onl
ine
appl
icatio
n in
stea
d of
a p
aper
app
licat
ion
if yo
u ar
e ab
le. T
he o
nlin
e ap
plica
tion
has t
he sa
me
requ
irem
ents
and
will
ask
you
for t
he sa
me
info
rmat
ion
as th
e pa
per a
pplic
atio
n. V
isit w
ww
.pcc
s.k1
2.in
.us t
o be
gin
or to
lear
n m
ore
abou
t the
onl
ine
appl
icatio
n pr
oces
s. Co
ntac
t Lor
a Hu
bert
, ECA
Tre
asur
er, 1
8677
Old
Sta
te R
oad
37, L
eopo
ld, I
N 4
7551
, 812
-843
-557
6, o
r by
emai
l lhu
bert
@pc
cs.k
12.in
.us,
if yo
u ha
ve a
ny q
uest
ions
abo
ut th
e on
line
appl
icatio
n.
6.
MY
CHIL
D’S
APPL
ICAT
ION
WAS
APP
ROVE
D LA
ST Y
EAR.
DO
I NE
ED T
O F
ILL O
UT A
NEW
ON
E? Y
es. Y
our c
hild
’s ap
plica
tion
is on
ly g
ood
for t
hat s
choo
l yea
r and
for t
he fi
rst
few
day
s of t
his s
choo
l yea
r thr
ough
Tue
sday
, Sep
tem
ber 1
8, 2
018.
You
mus
t sen
d in
a n
ew a
pplic
atio
n un
less
the
scho
ol to
ld y
ou th
at y
our c
hild
is e
ligib
le fo
r the
new
FEDE
RAL E
LIGI
BILI
TY IN
COM
E CH
ART
For S
choo
l Yea
r 201
8-19
Ho
useh
old
size
Year
ly
Mon
thly
W
eekl
y 1
22,4
59
1,87
2 43
2 2
30,4
51
2,53
8 58
6 3
38,4
43
3,20
4 74
0 4
46,4
35
3,87
0 89
3 5
54,4
27
4,53
6 1,
047
6 62
,419
5,
202
1,20
1 7
70,4
11
5,86
8 1,
355
8 78
,403
6,
534
1,50
8 Ea
ch a
dditi
onal
+7
,992
+6
66
+154
Pare
nt Le
tter
/Inst
ruct
ions
- PY
201
9
scho
ol y
ear.
If yo
u do
not
send
in a
new
app
licat
ion
that
is a
ppro
ved
by th
e sc
hool
or y
ou h
ave
not b
een
notif
ied
that
you
r chi
ld is
elig
ible
for f
ree
mea
ls, y
our c
hild
will
be
char
ged
the
full
price
of m
eals.
7.
I G
ET W
IC.
CAN
MY
CHIL
DREN
GET
FRE
E M
EALS
? C
hild
ren
in h
ouse
hold
s par
ticip
atin
g in
WIC
may
be
elig
ible
for f
ree
or re
duce
d pr
ice m
eals.
Ple
ase
send
in a
n ap
plica
tion.
8.
W
ILL T
HE IN
FORM
ATIO
N I
GIVE
BE
CHEC
KED?
Yes
. We
may
also
ask
you
to se
nd w
ritte
n pr
oof o
f the
hou
seho
ld in
com
e yo
u re
port
. 9.
IF
I DO
N’T
QUA
LIFY
NO
W, M
AY I
APPL
Y LA
TER?
Yes
, you
may
app
ly a
t any
tim
e du
ring
the
scho
ol y
ear.
For
exa
mpl
e, ch
ildre
n w
ith a
par
ent o
r gua
rdia
n w
ho b
ecom
es
unem
ploy
ed m
ay b
ecom
e el
igib
le fo
r fre
e an
d re
duce
d pr
ice
mea
ls if
the
hous
ehol
d in
com
e dr
ops b
elow
the
inco
me
limit.
10
. W
HAT
IF I
DISA
GREE
WIT
H TH
E SC
HOO
L’S
DECI
SIO
N AB
OUT
MY
APPL
ICAT
ION
? Yo
u sh
ould
talk
to sc
hool
offi
cials.
You
also
may
ask
for a
hea
ring
by c
allin
g or
writ
ing
to:
Mar
y Ro
bers
on, S
uper
inte
nden
t, 18
677
Old
Sta
te R
oad
37, L
eopo
ld, I
N 4
7551
, or b
y ph
one,
(812
) 843
-557
6, o
r by
emai
l mro
bers
on@
pccs
.k12
.in.u
s.
11.
MAY
I AP
PLY
IF S
OM
EONE
IN M
Y HO
USEH
OLD
IS N
OT
A U.
S. C
ITIZ
EN?
Yes.
You,
you
r chi
ldre
n, o
r oth
er h
ouse
hold
mem
bers
do
not h
ave
to b
e U.
S. ci
tizen
s to
appl
y fo
r fre
e or
redu
ced
price
mea
ls.
12.
WHA
T IF
MY
INCO
ME
IS N
OT
ALW
AYS
THE
SAM
E? Li
st th
e am
ount
that
you
nor
mal
ly re
ceiv
e. F
or e
xam
ple,
if y
ou n
orm
ally
mak
e $1
000
each
mon
th, b
ut y
ou m
issed
som
e w
ork
last
mon
th a
nd o
nly
mad
e $9
00, p
ut d
own
that
you
mad
e $1
000
per m
onth
. If
you
norm
ally
get
ove
rtim
e, in
clude
it, b
ut d
o no
t inc
lude
it if
you
onl
y w
ork
over
time
som
etim
es.
If yo
u ha
ve lo
st a
job
or h
ad y
our h
ours
or w
ages
redu
ced,
use
you
r cur
rent
inco
me.
13
. W
HAT
IF S
OM
E HO
USEH
OLD
MEM
BERS
HAV
E NO
INCO
ME
TO R
EPO
RT?
Hous
ehol
d m
embe
rs m
ay n
ot re
ceiv
e so
me
type
s of i
ncom
e w
e as
k yo
u to
repo
rt o
n th
e ap
plica
tion,
or m
ay n
ot re
ceiv
e in
com
e at
all.
Whe
neve
r thi
s hap
pens
, ple
ase
writ
e a
0 in
the
field
. How
ever
, if a
ny in
com
e fie
lds a
re le
ft em
pty
or b
lank
, tho
se w
ill a
lso b
e co
unte
d as
zero
es. P
leas
e be
car
eful
whe
n le
avin
g in
com
e fie
lds b
lank
, as w
e w
ill a
ssum
e yo
u m
eant
to d
o so
. 14
. W
E AR
E IN
THE
MIL
ITAR
Y. D
O W
E RE
PORT
OUR
INCO
ME
DIFF
EREN
TLY?
You
r bas
ic pa
y an
d ca
sh b
onus
es m
ust b
e re
port
ed a
s inc
ome.
If y
ou g
et a
ny ca
sh v
alue
allo
wan
ces
for o
ff-ba
se h
ousin
g, fo
od, o
r clo
thin
g, it
mus
t also
be
inclu
ded
as in
com
e. H
owev
er, i
f you
r hou
sing
is pa
rt o
f the
Mili
tary
Hou
sing
Priv
atiza
tion
Initi
ativ
e, d
o no
t inc
lude
yo
ur h
ousin
g al
low
ance
as i
ncom
e. A
ny a
dditi
onal
com
bat p
ay re
sulti
ng fr
om d
eplo
ymen
t is a
lso e
xclu
ded
from
inco
me.
15
. W
HAT
IF T
HERE
ISN’
T EN
OUG
H SP
ACE
ON
THE
APPL
ICAT
ION
FOR
MY
FAM
ILY?
List
any
add
ition
al h
ouse
hold
mem
bers
on
a se
para
te p
iece
of p
aper
, and
att
ach
it to
you
r ap
plica
tion.
Con
tact
Lor
a Hu
bert
, ECA
Tre
asur
er, 1
8677
Old
Sta
te R
oad
37, L
eopo
ld, I
N 4
7551
, or b
y ph
one
(812
) 843
-557
6, o
r by
emai
l lhu
bert
@pc
cs.k
12.in
.us
to re
ceiv
e a
seco
nd a
pplic
atio
n.
16.
MY
FAM
ILY
NEED
S M
ORE
HEL
P. A
RE T
HERE
OTH
ER P
ROGR
AMS
WE
MIG
HT A
PPLY
FO
R? T
o fin
d ou
t how
to a
pply
for S
NAP
(Foo
d St
amp)
or o
ther
ass
istan
ce b
enef
its,
cont
act y
our l
ocal
ass
istan
ce o
ffice
or c
all 1
-800
-403
-086
4.
If yo
u ha
ve o
ther
que
stio
ns o
r nee
d he
lp, c
all (
812)
843
-557
6.
Sinc
erel
y,
Mar
y Ro
bers
on
Supe
rinte
nden
t Pe
rry
Cent
ral C
omm
unity
Sch
ool C
orpo
ratio
n
Pare
nt Le
tter
/Inst
ruct
ions
- PY
201
9
HOW
TO
APP
LY F
OR
FREE
AND
RED
UCED
PRI
CE S
CHO
OL M
EALS
Pl
ease
use
thes
e in
stru
ctio
ns to
hel
p yo
u fil
l out
the
appl
icatio
n fo
r fre
e or
redu
ced
price
scho
ol m
eals.
You
onl
y ne
ed to
sub
mit
one
appl
icatio
n pe
r hou
seho
ld, e
ven
if yo
ur
child
ren
atte
nd m
ore
than
one
scho
ol in
Per
ry C
entr
al C
omm
unity
Sch
ool C
orpo
ratio
n. T
he a
pplic
atio
n m
ust b
e fil
led
out c
ompl
etel
y to
cert
ify y
our c
hild
ren
for f
ree
or re
duce
d pr
ice sc
hool
mea
ls. P
leas
e fo
llow
thes
e in
stru
ctio
ns in
ord
er! E
ach
step
of t
he in
stru
ctio
ns is
the
sam
e as
the
step
s on
your
app
licat
ion.
If a
t any
tim
e yo
u ar
e no
t sur
e w
hat t
o do
ne
xt, p
leas
e co
ntac
t Per
ry C
entr
al C
omm
unity
Sch
ool C
orpo
ratio
n, Lo
ra H
uber
t, EC
A Tr
easu
rer a
t (81
2) 8
43-5
576,
or b
y em
ail l
hube
rt@
pccs
.k12
.in.u
s.
PLEA
SE U
SE A
PEN
(NO
T A
PENC
IL) W
HEN
FIL
LING
OUT
THE
APP
LICA
TIO
N AN
D DO
YO
UR
BEST
TO
PRI
NT
CLEA
RLY.
STEP
2: D
O A
NY H
OUS
EHO
LD M
EMBE
RS C
URRE
NTLY
PAR
TICI
PATE
IN S
NAP
or T
ANF?
If
anyo
ne in
you
r hou
seho
ld (i
nclu
ding
you
) cur
rent
ly p
artic
ipat
es in
one
or m
ore
of th
e as
sista
nce
prog
ram
s list
ed b
elow
, you
r chi
ldre
n ar
e el
igib
le fo
r fre
e sc
hool
mea
ls:
Th
e Su
pple
men
tal N
utrit
ion
Assis
tanc
e Pr
ogra
m (S
NAP)
.
Tem
pora
ry A
ssist
ance
for N
eedy
Fam
ilies
(TAN
F).
STEP
1: L
IST
ALL I
NFAN
TS, C
HILD
REN,
AND
STU
DENT
S UP
TO
AND
INCL
UDIN
G GR
ADE
12 IN
THE
HO
USEH
OLD
Te
ll us
how
man
y in
fant
s, ch
ildre
n, a
nd sc
hool
stud
ents
live
in y
our h
ouse
hold
. The
y do
NO
T ha
ve to
be
rela
ted
to y
ou to
be
a pa
rt o
f you
r hou
seho
ld.
Who
shou
ld I
list h
ere?
Whe
n fil
ling
out t
his s
ectio
n, p
leas
e in
clude
ALL
mem
bers
in y
our h
ouse
hold
who
are
:
Child
ren
age
18 o
r und
er A
ND a
re su
ppor
ted
with
the
hous
ehol
d’s i
ncom
e;
In
you
r car
e un
der a
fost
er a
rran
gem
ent,
or q
ualif
y as
hom
eles
s, m
igra
nt, o
r run
away
you
th;
St
uden
ts a
tten
ding
Per
ry C
entr
al C
omm
unity
Sch
ool C
orpo
ratio
n, re
gard
less
of a
ge.
A) Li
st e
ach
child
’s n
ame.
Prin
t eac
h ch
ild’s
nam
e. U
se o
ne li
ne o
f the
app
licat
ion
for e
ach
child
. If t
here
are
mor
e ch
ildre
n pr
esen
t tha
n lin
es o
n th
e ap
plica
tion,
atta
ch a
seco
nd p
iece
of
pap
er w
ith a
ll re
quire
d in
form
atio
n fo
r the
ad
ditio
nal c
hild
ren.
B) Is
the
child
a st
uden
t at P
erry
Ce
ntra
l Com
mun
ity S
choo
l Co
rpor
atio
n? M
ark
‘Yes
’ or ‘
No’
unde
r the
colu
mn
title
d “S
tude
nt”
to te
ll us
whi
ch ch
ildre
n at
tend
Pe
rry
Cent
ral C
omm
unity
Sch
ool
Corp
orat
ion.
If y
ou m
arke
d ‘Y
es,’
writ
e th
e na
me
of th
e sc
hool
bu
ildin
g, b
irthd
ate,
and
gra
de
leve
l of t
he st
uden
t in
the
‘Gra
de’
colu
mn
to th
e rig
ht.
Is th
e ch
ild li
ving
with
par
ent o
r ca
reta
ker r
elat
ive?
Mar
k ‘Y
es’ o
r ‘N
o’ n
ext t
o ea
ch ch
ild.
C) D
o yo
u ha
ve a
ny fo
ster
child
ren?
If a
ny ch
ildre
n lis
ted
are
fost
er ch
ildre
n, m
ark
the
“Fos
ter C
hild
” bo
x nex
t to
the
child
’s na
me.
If y
ou a
re O
NLY
appl
ying
for f
oste
r chi
ldre
n, a
fter f
inish
ing
STEP
1,
go to
STE
P 4.
Fo
ster
child
ren
who
live
with
you
may
coun
t as
mem
bers
of y
our h
ouse
hold
and
shou
ld b
e lis
ted
on
your
app
licat
ion.
If y
ou a
re a
pply
ing
for b
oth
fost
er
and
non-
fost
er ch
ildre
n, g
o to
step
3.
D) A
re a
ny ch
ildre
n ho
mel
ess,
mig
rant
, or
runa
way
? If
you
belie
ve a
ny ch
ild
liste
d in
this
sect
ion
mee
ts th
is de
scrip
tion,
mar
k th
e “H
omel
ess,
Mig
rant
, Run
away
” box
nex
t to
the
child
’s na
me
and
com
plet
e al
l ste
ps o
f th
e ap
plica
tion.
Pare
nt Le
tter
/Inst
ruct
ions
- PY
201
9
A) I
f no
one
in y
our h
ouse
hold
par
ticip
ates
in a
ny o
f the
abo
ve
liste
d pr
ogra
ms:
Leav
e ST
EP 2
bla
nk a
nd g
o to
STE
P 3.
B) I
f any
one
in y
our h
ouse
hold
par
ticip
ates
in a
ny o
f the
abo
ve li
sted
pro
gram
s:
W
rite
a ca
se n
umbe
r for
SNA
P or
TAN
F. Y
ou o
nly
need
to p
rovi
de o
ne ca
se n
umbe
r. If
you
part
icipa
te in
one
of
thes
e pr
ogra
ms a
nd d
o no
t kno
w y
our c
ase
num
ber,
cont
act:
1-80
0-40
3-08
64.
Go
to S
TEP
4.
STEP
3: R
EPO
RT IN
COM
E FO
R AL
L HO
USEH
OLD
MEM
BERS
Ho
w d
o I r
epor
t my
inco
me?
Use
the
char
ts ti
tled
“Sou
rces
of I
ncom
e fo
r Adu
lts” a
nd “
Sour
ces o
f Inc
ome
for C
hild
ren,
” lo
cate
d be
low
to d
eter
min
e if
your
hou
seho
ld h
as in
com
e to
repo
rt.
R e p o r t a l l a m o unt
s in
GRO
SS IN
COM
E O
NLY.
Rep
ort a
ll in
com
e in
who
le d
olla
rs. D
o no
t inc
lude
cent
s.
o Gr
oss i
ncom
e is
the
tota
l inc
ome
rece
ived
bef
ore
taxe
s o
Man
y pe
ople
thin
k of
inco
me
as th
e am
ount
they
“tak
e ho
me”
and
not
the
tota
l, “g
ross
” am
ount
. Mak
e su
re th
at th
e in
com
e yo
u re
port
on
this
appl
icatio
n ha
s NO
T be
en
redu
ced
to p
ay fo
r tax
es, i
nsur
ance
pre
miu
ms,
or a
ny o
ther
am
ount
s tak
en fr
om y
our p
ay.
W
rite
a “0
” in
any
field
s whe
re th
ere
is no
inco
me
to re
port
. Any
inco
me
field
s lef
t em
pty
or b
lank
will
also
be
coun
ted
as a
zero
. If y
ou w
rite
‘0’ o
r lea
ve a
ny fi
elds
bla
nk, y
ou a
re
cert
ifyin
g (p
rom
ising
) tha
t the
re is
no
inco
me
to re
port
. If l
ocal
offi
cials
susp
ect t
hat y
our h
ouse
hold
inco
me
was
repo
rted
inco
rrec
tly, y
our a
pplic
atio
n w
ill b
e in
vest
igat
ed.
M
ark
how
ofte
n ea
ch ty
pe o
f inc
ome
is re
ceiv
ed u
sing
the
chec
k bo
xes t
o th
e rig
ht o
f eac
h fie
ld.
Sou
rces
of I
ncom
e fo
r C
hild
ren
Sour
ces o
f Chil
d Inc
ome
Exam
ple(s)
- E
arni
ngs
from
wor
k - A
chi
ld h
as a
regu
lar f
ull o
r par
t-tim
e jo
b w
here
they
ear
n a
sala
ry o
r wag
es
- So
cial
Sec
urity
-
Dis
abilit
y Pa
ymen
ts
- Su
rviv
or’s
Ben
efits
- A
chi
ld is
blin
d or
disa
bled
and
rece
ives
Socia
l Sec
urity
ben
efits
- A
Par
ent i
s di
sabl
ed, r
etire
d, o
r dec
ease
d,
and
thei
r chi
ld re
ceive
s So
cial S
ecur
ity
bene
fits
-Inco
me
from
per
son
outs
ide
the
hous
ehol
d - A
frie
nd o
r ext
ende
d fa
mily
m
embe
r reg
ular
ly g
ives
a c
hild
sp
endi
ng m
oney
-In
com
e fro
m a
ny o
ther
sou
rce
- A c
hild
rece
ives
regu
lar i
ncom
e fro
m a
priv
ate
pens
ion
fund
, ann
uity
, or
trus
t
Sou
rces
of I
ncom
e fo
r A
dults
Ea
rning
s fro
m W
ork
Publi
c Ass
istan
ce /
Alim
ony /
Chil
d Sup
port
Pens
ions /
Reti
rem
ent /
All
Othe
r Inco
me
- Sal
ary,
wag
es, c
ash
bonu
ses
- Net
inco
me
from
sel
f- em
ploy
men
t (fa
rm o
r bu
sine
ss)
If yo
u ar
e in
the
U.S
. Milit
ary:
- Bas
ic pa
y and
cash
bonu
ses
(do N
OT
includ
e com
bat p
ay,
FSSA
or p
rivat
ized h
ousin
g all
owan
ces)
- A
llowa
nces
for o
ff-ba
se
hous
ing, fo
od an
d clot
hing
- U
nem
ploy
men
t ben
efits
-
Wor
ker’s
com
pens
atio
n
- Sup
plem
enta
l Sec
urity
In
com
e (S
SI)
- C
ash
assi
stan
ce fr
om
Stat
e or
loca
l gov
ernm
ent
- A
limon
y pa
ymen
ts
- C
hild
sup
port
paym
ents
- Vet
eran
’s b
enefi
ts
- S
trike
ben
efits
- So
cial
Sec
urity
(inc
ludi
ng
railr
oad
retir
emen
t and
bla
ck
lung
ben
efits
) -
Priv
ate
pens
ions
or
disa
bilit
y be
nefit
s -
Reg
ular
inco
me
from
tru
sts
or e
stat
es
- An
nuiti
es
- In
vest
men
t inc
ome
- Ea
rned
inte
rest
-
Ren
tal i
ncom
e -
Reg
ular
cas
h pa
ymen
ts fr
om
outs
ide
hous
ehol
d
3.A.
REP
ORT
INCO
ME
EARN
ED B
Y CH
ILDR
EN
A) R
epor
t all
inco
me
earn
ed o
r rec
eive
d by
child
ren.
Rep
ort t
he co
mbi
ned
gros
s inc
ome
for A
LL ch
ildre
n lis
ted
in S
TEP
1 in
you
r hou
seho
ld in
the
box
mar
ked
“Chi
ld In
com
e.” O
nly
coun
t fos
ter c
hild
ren’
s inc
ome
if yo
u ar
e ap
plyi
ng fo
r the
m to
geth
er w
ith th
e re
st o
f you
r hou
seho
ld.
Wha
t is C
hild
Inco
me?
Chi
ld in
com
e is
mon
ey re
ceiv
ed fr
om o
utsid
e yo
ur h
ouse
hold
that
is p
aid
DIRE
CTLY
to y
our c
hild
ren.
Man
y ho
useh
olds
do
not h
ave
any
child
inco
me.
3.
B R
EPO
RT IN
COM
E EA
RNED
BY
ADUL
TS
Who
shou
ld I
list h
ere?
Whe
n fil
ling
out t
his s
ectio
n, p
leas
e in
clude
ALL
adu
lt m
embe
rs in
you
r hou
seho
ld w
ho a
re li
ving
with
you
and
shar
e in
com
e an
d ex
pens
es, e
ven
if th
ey a
re n
ot re
late
d an
d ev
en if
they
do
not r
ecei
ve in
com
e of
thei
r ow
n.
Do
NO
T in
clude
:
Pare
nt Le
tter
/Inst
ruct
ions
- PY
201
9
o Pe
ople
who
live
with
you
but
are
not
supp
orte
d by
you
r hou
seho
ld’s
inco
me
AND
do n
ot co
ntrib
ute
inco
me
to y
our h
ouse
hold
. o
Infa
nts,
Child
ren
and
stud
ents
alre
ady
liste
d in
STE
P 1.
B)
List
adu
lt ho
useh
old
mem
bers
’ na
mes
. Prin
t the
nam
e of
eac
h ho
useh
old
mem
ber i
n th
e bo
xes m
arke
d “N
ames
of A
dult
Hous
ehol
d M
embe
rs
(Firs
t and
Last
).” D
o no
t list
any
ho
useh
old
mem
bers
you
list
ed in
STE
P 1.
If
a ch
ild li
sted
in S
TEP
1 ha
s inc
ome,
fo
llow
the
inst
ruct
ions
in S
TEP
3, p
art A
.
C) R
epor
t ear
ning
s fro
m w
ork.
Rep
ort a
ll in
com
e fro
m w
ork
in th
e “E
arni
ngs f
rom
Wor
k” fi
eld
on th
e ap
plica
tion.
Thi
s is u
sual
ly th
e m
oney
rece
ived
from
wor
king
at j
obs.
If yo
u ar
e a
self-
empl
oyed
bu
sines
s or f
arm
ow
ner,
you
will
repo
rt y
our n
et in
com
e.
Wha
t if I
am
self-
empl
oyed
? Re
port
inco
me
from
that
wor
k as
a n
et
amou
nt. T
his i
s cal
cula
ted
by su
btra
ctin
g th
e to
tal o
pera
ting
expe
nses
of y
our b
usin
ess f
rom
its g
ross
rece
ipts
or r
even
ue.
D) R
epor
t inc
ome
from
pub
lic a
ssist
ance
/chi
ld
supp
ort/
alim
ony.
Rep
ort a
ll in
com
e th
at a
pplie
s in
the
“Pub
lic
Assis
tanc
e/Ch
ild S
uppo
rt/A
limon
y” fi
eld
on th
e ap
plica
tion.
Do
not r
epor
t the
cash
val
ue o
f any
pub
lic a
ssist
ance
ben
efits
NO
T lis
ted
on th
e ch
art.
If in
com
e is
rece
ived
from
child
supp
ort o
r al
imon
y, o
nly
repo
rt c
ourt
-ord
ered
pay
men
ts. I
nfor
mal
but
re
gula
r pay
men
ts sh
ould
be
repo
rted
as “
othe
r” in
com
e in
the
next
par
t.
E) R
epor
t inc
ome
from
pe
nsio
ns/r
etire
men
t/al
l oth
er in
com
e.
Repo
rt a
ll in
com
e th
at a
pplie
s in
the
“Pen
sions
/Ret
irem
ent/
All
Oth
er
Inco
me”
fiel
d on
the
appl
icatio
n.
F) R
epor
t tot
al h
ouse
hold
size
. Ent
er th
e to
tal n
umbe
r of h
ouse
hold
m
embe
rs in
the
field
“Tot
al H
ouse
hold
Mem
bers
(Chi
ldre
n an
d Ad
ults
).” T
his n
umbe
r MUS
T be
equ
al to
the
num
ber o
f hou
seho
ld
mem
bers
list
ed in
STE
P 1
and
STEP
3. I
f the
re a
re a
ny m
embe
rs o
f yo
ur h
ouse
hold
that
you
hav
e no
t list
ed o
n th
e ap
plica
tion,
go
back
an
d ad
d th
em. I
t is v
ery
impo
rtan
t to
list a
ll ho
useh
old
mem
bers
, as
the
size
of y
our h
ouse
hold
affe
cts y
our e
ligib
ility
for f
ree
and
redu
ced
price
mea
ls.
G) P
rovi
de th
e la
st fo
ur d
igits
of y
our S
ocia
l Sec
urity
Num
ber.
An a
dult
hous
ehol
d m
embe
r mus
t ent
er th
e la
st fo
ur d
igits
of
thei
r Soc
ial S
ecur
ity N
umbe
r in
the
spac
e pr
ovid
ed. Y
ou a
re
elig
ible
to a
pply
for b
enef
its e
ven
if yo
u do
not
hav
e a
Socia
l Se
curit
y Nu
mbe
r. If
no a
dult
hous
ehol
d m
embe
rs h
ave
a So
cial
Secu
rity
Num
ber,
leav
e th
is sp
ace
blan
k an
d m
ark
the
box t
o th
e rig
ht la
bele
d “C
heck
if n
o SS
N.”
STEP
4: C
ONT
ACT
INFO
RMAT
ION
AND
ADUL
T SI
GNAT
URE
All a
pplic
atio
ns m
ust b
e sig
ned
by a
n ad
ult m
embe
r of t
he h
ouse
hold
. By
signi
ng th
e ap
plica
tion,
that
hou
seho
ld m
embe
r is p
rom
ising
that
all
info
rmat
ion
has b
een
trut
hful
ly
and
com
plet
ely
repo
rted
. Bef
ore
com
plet
ing
this
sect
ion,
ple
ase
also
mak
e su
re y
ou h
ave
read
the
priv
acy
and
civil
right
s sta
tem
ents
on
the
back
of t
he a
pplic
atio
n.
A) P
rint a
nd si
gn y
our n
ame.
Prin
t the
na
me
of th
e ad
ult s
igni
ng th
e ap
plica
tion
and
that
per
son
signs
in th
e bo
x “S
igna
ture
of
adu
lt.”
B) P
rovi
de y
our c
onta
ct in
form
atio
n.
Writ
e yo
ur cu
rren
t add
ress
in th
e fie
lds
prov
ided
if th
is in
form
atio
n is
avai
labl
e. If
yo
u ha
ve n
o pe
rman
ent a
ddre
ss, t
his d
oes
not m
ake
your
child
ren
inel
igib
le fo
r fre
e or
redu
ced
price
scho
ol m
eals.
Sha
ring
a ph
one
num
ber,
emai
l add
ress
, or b
oth
is op
tiona
l, bu
t hel
ps u
s rea
ch y
ou q
uick
ly if
w
e ne
ed to
cont
act y
ou.
C) M
ail C
ompl
eted
For
m to
: Per
ry C
entr
al
Com
mun
ity S
choo
l Cor
pora
tion,
ATT
N:
Lora
Hub
ert,
ECA
Trea
sure
r, 18
677
Old
St
ate
Road
37,
Leop
old,
IN 4
7551
D) S
hare
child
ren’
s rac
ial a
nd e
thni
c id
entit
ies (
optio
nal).
On
the
back
of t
he
appl
icatio
n, w
e as
k yo
u to
shar
e in
form
atio
n ab
out y
our c
hild
ren’
s rac
e an
d et
hnici
ty. T
his f
ield
is o
ptio
nal a
nd d
oes
not a
ffect
you
r chi
ldre
n’s e
ligib
ility
for f
ree
or re
duce
d pr
ice sc
hool
mea
ls.
STEP
5: O
THER
BEN
EFIT
S –
OPT
IONA
L Th
e fo
llow
ing
sect
ions
are
opt
iona
l and
do
not a
ffect
you
r chi
ldre
n’s e
ligib
ility
for f
ree
or re
duce
d pr
ice sc
hool
mea
ls.
A) T
extb
ook
Assis
tanc
e If
you
wan
t to
rece
ive
text
book
ass
istan
ce, c
heck
‘Yes
’ and
then
read
, sig
n, a
nd d
ate
the
sect
ion
to th
e rig
ht. I
f you
do
not w
ant t
o re
ceiv
e te
xtbo
ok a
ssist
ance
, che
ck ‘N
o’.
B) H
oosie
r Hea
lthw
ise D
isclo
sure
If
you
wan
t to
shar
e yo
ur ch
ild’s
free/
redu
ced
elig
ibili
ty in
ord
er to
qua
lify
for f
ree
or
low
-cos
t hea
lth in
sura
nce
unde
r Med
icaid
or H
oosie
r Hea
lthw
ise, s
ign
and
date
this
sect
ion.
PER
RY
CEN
TRAL
CO
MM
UNI
TY S
CHO
OL
CORP
OR
ATIO
N
2018
-201
9 Ho
useh
old
Appl
icat
ion
for F
ree
and
Redu
ced
Pric
e Sc
hool
Mea
ls
Com
plet
e on
e ap
plic
atio
n pe
r hou
seho
ld. P
leas
e us
e a
pen
(not
a p
enci
l).
Pres
crib
ed b
y St
ate
Boar
d of
Acc
ount
s Sc
hool
For
m N
o. 5
21/2
018
STEP
1 Li
st A
LL in
fant
s, c
hild
ren,
and
stu
dent
s up
to g
rade
12
who
are
mem
bers
of y
our h
ouse
hold
(if m
ore
spac
es a
re re
quire
d fo
r add
itiona
l nam
es, a
ttach
ano
ther
she
et o
f pap
er)
Def
initi
on o
f Hou
seho
ld
Mem
ber:
“Any
one
who
is
livin
g w
ith y
ou a
nd s
hare
s in
com
e an
d ex
pens
es,
even
if n
ot re
late
d.”
Chi
ldre
n in
Fos
ter c
are
and
child
ren
who
mee
t the
de
finitio
n of
Hom
eles
s,
Mig
rant
or R
unaw
ay a
re
elig
ible
for f
ree
mea
ls. R
ead
How
to A
pply
for F
ree
and
Redu
ced
Pric
e Sc
hool
M
eals
for m
ore
info
rmat
ion.
Chi
ld’s
Firs
t Nam
e M
I C
hild
’s L
ast N
ame
Fost
er
Chi
ld
Hom
eles
s,
Mig
rant
, R
unaw
ay
Stud
ent?
Ye
s N
o
STEP
2
Do a
ny H
ouse
hold
Mem
bers
(inc
ludi
ng y
ou) c
urre
ntly
par
ticip
ate
in o
ne o
r mor
e of
the
follo
win
g as
sist
ance
pro
gram
s: S
NAP
(Foo
d St
amp)
or T
ANF?
If NO
> G
o to
STE
P 3.
If
YES
> W
rite
a ca
se n
umbe
r her
e th
en g
o to
STE
P 4
(Do
not c
ompl
ete
STEP
3)
Case
Num
ber:
/
/
/
/
/
/
/ /
/
Writ
e on
ly o
ne c
ase
num
ber i
n th
is s
pace
.
STEP
3
Repo
rt In
com
e fo
r ALL
Hou
seho
ld M
embe
rs (S
kip
this
ste
p if
you
answ
ered
‘Yes
’ to
STEP
2)
How
ofte
n?
A. C
hild
Inco
me
Som
etim
es c
hild
ren
in th
e ho
useh
old
earn
or r
ecei
ve in
com
e. P
leas
e in
clud
e th
e TO
TAL
inco
me
rece
ived
by
all c
hild
ren
in h
ouse
hold
list
ed in
STE
P 1
here
.
Child
inco
me
W
eekl
y
Ever
y 2
Wks
2
x M
onth
M
onth
ly
$ B.
All
Adul
t Hou
seho
ld M
embe
rs (i
nclu
ding
you
rsel
f) Li
st a
ll H
ouse
hold
Mem
bers
not
list
ed in
STE
P 1
(incl
udin
g yo
urse
lf) e
ven
if th
ey d
o no
t rec
eive
inco
me.
For
eac
h H
ouse
hold
Mem
ber l
iste
d, if
they
do
rece
ive
inco
me,
repo
rt to
tal (
gros
s) in
com
e be
fore
any
taxe
s or
ded
uctio
ns fo
r eac
h so
urce
in w
hole
dol
lars
(no
cent
s) o
nly.
If th
ey d
o no
t rec
eive
inco
me
from
any
sou
rce,
writ
e ‘0
’. If
you
ente
r ‘0’
or l
eave
any
fiel
ds b
lank
, you
are
cer
tifyi
ng
(pro
mis
ing)
that
ther
e is
no
inco
me
to re
port.
Ho
w of
ten?
Pu
blic
Ass
ista
nce/
C
hild
Sup
port/
Alim
ony
How
ofte
n?
Pens
ions
/Ret
irem
ent/
All O
ther
Inco
me
How
ofte
n?
Nam
e of
Adu
lt H
ouse
hold
Mem
bers
(Firs
t and
Las
t) Ea
rnin
gs fr
om W
ork
W
eekl
y E
very
2 W
ks 2
x M
onth
Mon
thly
$
$
$
$
$
$
$
$ $
$
$ $
$
$ $
Tota
l Hou
seho
ld M
embe
rs
(Chi
ldre
n an
d A
dults
) La
st F
our D
igits
of S
ocia
l Sec
urity
Num
ber (
SSN)
of
Prim
ary
Wag
e Ea
rner
or O
ther
Adu
lt Ho
useh
old
Mem
ber
X
X
X
X X
Ch
eck
if no
SSN
“I ce
rtify
(pro
mis
e) th
at a
ll in
form
atio
n on
this
app
licat
ion
is tr
ue a
nd th
at a
ll in
com
e is
repo
rted.
I un
ders
tand
that
thi
s in
form
atio
n is
giv
en in
con
nect
ion
with
the
rece
ipt o
f Fed
eral
fund
s, a
nd th
at s
choo
l offi
cial
s m
ay v
erify
(che
ck) t
he in
form
atio
n. I
am a
war
e th
at if
I pu
rpos
ely
give
fa
lse
info
rmat
ion,
my
child
ren
may
lose
mea
l ben
efits
, and
I m
ay b
e pr
osec
uted
und
er a
pplic
able
Sta
te a
nd F
eder
al la
ws.
”
Stre
et A
ddre
ss (i
f ava
ilabl
e)
Apt #
C
ity
Stat
e Zi
p D
aytim
e Ph
one
and
Emai
l (op
tiona
l)
Prin
ted
nam
e of
adu
lt co
mpl
etin
g th
e fo
rm
Sign
atur
e of
adu
lt co
mpl
etin
g th
e fo
rm
Toda
y’s d
ate
Con
tact
info
rmat
ion
and
adul
t sig
natu
re. M
ail C
ompl
eted
For
m T
o: 1
8677
Old
Sta
te R
oad
37, L
eopo
ld, I
N 4
7551
T
urn
for T
extb
ook
Ben
efits
W
eekl
y E
very
2 W
ks 2
x M
onth
Mon
thly
Onl
y St
uden
ts:
Birth
date
Onl
y St
uden
ts:
Gra
de
W
eekl
y E
very
2 W
ks 2
x M
onth
Mon
thly
Onl
y St
uden
ts:
Nam
e of
Sch
ool B
uild
ing
STEP
4
Livi
ng w
ith p
aren
t or
care
take
r rel
ativ
e?
Yes
No
Check all that apply
Are
you
unsu
re w
hat
to d
o he
re?
Pl
ease
read
How
to
App
ly fo
r Fre
e
and
Red
uced
Pric
e Sc
hool
Mea
ls fo
r m
ore
info
rmat
ion.
Th
e So
urce
s of
In
com
e fo
r Chi
ldre
n se
ctio
n w
ill he
lp
you
with
the
Chi
ld
Inco
me
ques
tion.
Th
e So
urce
s of
In
com
e fo
r Adu
lts
sect
ion
will
help
you
w
ith th
e A
ll A
dult
Hou
seho
ld M
embe
rs
sect
ion.
1 2 3 4 5
1 2 3 4 5
Do
you
wan
t to
rece
ive
Text
book
Ass
ista
nce?
OPT
IONA
L Ch
ildre
n's
Raci
al a
nd E
thni
c Id
entit
ies
We
are
requ
ired
to a
sk fo
r inf
orm
atio
n ab
out y
our c
hild
ren’
s ra
ce a
nd e
thni
city
. Thi
s in
form
atio
n is
impo
rtant
and
hel
ps to
mak
e su
re w
e ar
e fu
lly s
ervi
ng o
ur c
omm
unity
. Res
pond
ing
to th
is s
ectio
n is
opt
iona
l and
doe
s no
t affe
ct y
our c
hild
ren’
s el
igib
ility
for f
ree
or re
duce
d pr
ice
mea
ls.
Ethn
icity
(che
ck o
ne):
Race
(che
ck o
ne o
r mor
e):
His
pani
c or
Lat
ino
Not
His
pani
c or
Lat
ino
Amer
ican
Indi
an o
r Ala
skan
Nat
ive
Asia
n
Blac
k or
Afri
can
Amer
ican
STEP
5
Oth
er B
enef
its –
Thi
s se
ctio
n do
es n
ot n
eed
to b
e co
mpl
eted
to re
ceiv
e fre
e or
redu
ced
pric
e m
eal b
enef
its.
Yes
N
o If
yes,
sig
n to
the
righ
t
I cer
tify
that
I am
the
pare
nt/g
uard
ian
of th
e ch
ild(r
en) f
or w
hom
app
licat
ion
is b
ein
g m
ade.
My
sign
atur
e be
low
aut
horiz
es th
e re
leas
e of
in
form
atio
n on
this
app
licat
ion
for t
extb
ook
assi
stan
ce. I
giv
e up
my
right
of c
onfid
entia
lity
for t
his
purp
ose
only
. Thi
s ap
plic
atio
n in
form
atio
n w
ill b
e sh
ared
with
the
Indi
ana
Fam
ily a
nd S
ocia
l Ser
vice
s A
dmin
istra
tion
purs
uant
to I.
C. 2
0-33
-5-2
and
I.C
. 12-
14-2
8-2,
so
lely
for p
urpo
ses
of c
ompl
ying
with
45
C.F
.R. P
arts
260
and
265
.
Sign
atur
e of
adu
lt co
mpl
etin
g th
e fo
rm
Toda
y’s d
ate
Sch
ool U
se O
nly:
�
App
rove
d �
Den
ied
�
Not
App
licab
le
Th
is a
pplic
atio
n in
form
atio
n m
ay b
e sh
ared
with
the
Fam
ily a
nd S
ocia
l Ser
vice
s A
dmin
istra
tion
for t
he p
urpo
se o
f ide
ntify
ing
child
ren
who
may
qua
lify
for f
ree
or lo
w-c
ost h
ealth
insu
ranc
e un
der
Med
icai
d or
Hoo
sier
H
ealth
wis
e . If
you
wan
t the
app
licat
ion
info
rmat
ion
shar
ed fo
r thi
s pu
rpos
e, p
leas
e si
gn b
elow
. I c
ertif
y I a
m th
e pa
rent
/gua
rdia
n of
the
chi
ld(r
en) f
or w
hom
app
licat
ion
is b
eing
mad
e. I
auth
oriz
e th
e re
leas
e of
in
form
atio
n fo
r thi
s pu
rpos
e.
Sign
atur
e of
adu
lt co
mpl
etin
g th
e fo
rm
Toda
y’s d
ate
For i
nfor
mat
ion
abou
t Hoo
sier
Hea
lthw
ise
heal
th in
sura
nce,
ca
ll 1-
800-
889-
9949
.
Nat
ive
Haw
aiia
n or
Oth
er P
acifi
c Is
land
er
Whi
te
5
Pers
ons
with
dis
abilit
ies
who
requ
ire a
ltern
ativ
e m
eans
of c
omm
unic
atio
n fo
r pro
gram
info
rmat
ion
(e.g
. Bra
ille,
larg
e pr
int,
audi
otap
e, A
mer
ican
Sig
n La
ngua
ge, e
tc.),
sho
uld
cont
act t
he A
genc
y (S
tate
or l
ocal
) whe
re th
ey
appl
ied
for
bene
fits.
Indi
vidu
als
who
are
dea
f, ha
rd o
f hea
ring
or h
ave
spee
ch d
isab
ilitie
s m
ay c
onta
ct U
SDA
thro
ugh
the
Fede
ral
Rel
ay S
ervi
ce a
t (8
00)
877-
8339
. Ad
ditio
nally
, pr
ogra
m i
nfor
mat
ion
may
be
mad
e av
aila
ble
in
lang
uage
s ot
her t
han
Engl
ish.
To
file
a p
rogr
am c
ompl
aint
of d
iscr
imin
atio
n, c
ompl
ete
the
USD
A Pr
ogra
m D
iscr
imin
atio
n C
ompl
aint
Fo
rm,
(AD
-302
7) fo
und
onlin
e at
: http
://w
ww
.asc
r.usd
a.go
v/co
mpl
aint
_filin
g_cu
st.h
tml, a
nd a
t any
USD
A of
fice,
or
writ
e a
lette
r add
ress
ed to
USD
A an
d pr
ovid
e in
the
lette
r all o
f the
info
rmat
ion
requ
este
d in
the
form
. To
requ
est a
cop
y of
the
com
plai
nt fo
rm, c
all (
866)
632
-999
2. S
ubm
it yo
ur c
ompl
eted
form
or l
ette
r to
USD
A by
: m
ail:
U.S
. Dep
artm
ent o
f Agr
icul
ture
Offi
ce o
f the
Ass
ista
nt S
ecre
tary
for C
ivil
Rig
hts
1400
Inde
pend
ence
Ave
nue,
SW
Was
hing
ton,
D.C
. 202
50-9
410
fax:
(
202)
690
-744
2; o
r em
ail:
pro
gram
.inta
ke@
usda
.gov
Th
is in
stitu
tion
is a
n eq
ual o
ppor
tuni
ty p
rovi
der.
The
Ric
hard
B. R
usse
ll N
atio
nal S
choo
l Lun
ch A
ct re
quire
s th
e in
form
atio
n on
this
app
licat
ion.
You
do
not
have
to g
ive
the
info
rmat
ion,
but
if y
ou d
o no
t, w
e ca
nnot
app
rove
you
r chi
ld fo
r fre
e or
redu
ced
pric
e m
eals
. Yo
u m
ust i
nclu
de th
e la
st fo
ur d
igits
of t
he s
ocia
l sec
urity
num
ber o
f the
adu
lt ho
useh
old
mem
ber w
ho s
igns
the
appl
icat
ion.
The
last
four
dig
its o
f the
soc
ial s
ecur
ity n
umbe
r is
not r
equi
red
whe
n yo
u ap
ply
on b
ehal
f of a
fost
er
child
or y
ou li
st a
Sup
plem
enta
l Nut
ritio
n As
sist
ance
Pro
gram
(SN
AP),
Tem
pora
ry A
ssis
tanc
e fo
r Nee
dy
Fam
ilies
(TAN
F) P
rogr
am o
r Foo
d D
istri
butio
n Pr
ogra
m o
n In
dian
Res
erva
tions
(FD
PIR
) cas
e nu
mbe
r or o
ther
FD
PIR
iden
tifier
for y
our c
hild
or w
hen
you
indi
cate
that
the
adul
t hou
seho
ld m
embe
r sig
ning
the
appl
icat
ion
does
not
hav
e a
soci
al s
ecur
ity n
umbe
r. W
e w
ill us
e yo
ur in
form
atio
n to
det
erm
ine
if yo
ur c
hild
is e
ligib
le fo
r fre
e or
redu
ced
pric
e m
eals
, and
for a
dmin
istra
tion
and
enfo
rcem
ent o
f the
lunc
h an
d br
eakf
ast p
rogr
ams.
We
MA
Y sh
are
your
elig
ibilit
y in
form
atio
n w
ith e
duca
tion,
hea
lth, a
nd n
utrit
ion
prog
ram
s to
hel
p th
em e
valu
ate,
fund
, or
dete
rmin
e be
nefit
s fo
r the
ir pr
ogra
ms,
aud
itors
for p
rogr
am re
view
s, a
nd la
w e
nfor
cem
ent o
ffici
als
to h
elp
them
lo
ok in
to v
iola
tions
of p
rogr
am ru
les.
In
acc
orda
nce
with
Fed
eral
civ
il rig
hts
law
and
U.S
. Dep
artm
ent o
f Agr
icul
ture
(USD
A) c
ivil
right
s re
gula
tions
and
po
licie
s, th
e U
SDA,
its
Age
ncie
s, o
ffice
s, a
nd e
mpl
oyee
s, a
nd in
stitu
tions
par
ticip
atin
g in
or a
dmin
iste
ring
USD
A pr
ogra
ms
are
proh
ibite
d fro
m d
iscr
imin
atin
g ba
sed
on ra
ce, c
olor
, nat
iona
l orig
in, s
ex, d
isab
ility
, age
, or r
epris
al
or re
talia
tion
for p
rior c
ivil
right
s ac
tivity
in a
ny p
rogr
am o
r act
ivity
con
duct
ed o
r fun
ded
by U
SDA.
FOR
SC
HO
OL
USE
ON
LY –
DO
NO
T W
RIT
E B
ELO
W T
HIS
LIN
E IN
CO
ME
CO
NVE
RS
ION
to Y
EAR
LY:
WEE
KLY
X 52
EV
ERY
2 W
EEKS
X 2
6 TW
ICE
A M
ON
TH X
24
MO
NTH
LY X
12
ELIG
IBIL
ITY
DETE
RMIN
ATIO
N
Inco
me
Elig
ibilit
y: T
otal
Hou
seho
ld S
ize:
____
__
Tota
l Inc
ome:
$___
____
____
pe
r: �
Wee
kly
� E
very
2 W
eeks
�
Mon
thly
�
Tw
ice
a M
onth
� Y
early
OR
Cat
egor
ical
Elig
ibilit
y: �
Foo
d St
amps
/TAN
F
� M
igra
nt
�
Hom
eles
s
�
Run
away
� F
oste
r El
igib
ility
Det
erm
inat
ion:
� A
ppro
ved
Free
�
App
rove
d R
educ
ed P
rice
�
Den
ied
R
easo
n fo
r Den
ial:
� In
com
e To
o H
igh
�
Inco
mpl
ete
Appl
icat
ion
�
Oth
er__
____
____
____
____
____
_ Ty
pe o
f Elig
ibili
ty N
otifi
catio
n Pr
ovid
ed (i
f den
ied,
not
ifica
tion
mus
t be
writ
ten)
: �
Verb
al �
Writ
ten
Dat
e:__
____
____
Si
gnat
ure
of D
eter
min
ing
Offi
cial
: ___
____
____
____
____
____
____
____
____
____
____
____
Dat
e:__
____
____
__
Dat
e W
ithdr
awn:
___
____
____
___
VERI
FIC
ATIO
N
Con
firm
atio
n R
evie
w O
ffici
al: _
____
____
____
____
____
____
____
____
____
____
____
__ A
pplic
atio
n D
irect
Ver
ified
? Ye
s �
No
�
Dat
e V
erifi
catio
n N
otic
e Se
nt:_
____
____
____
___
Dat
e R
espo
nse
Due
from
Hou
seho
lds:
____
____
__
Dat
e S
econ
d N
otic
e S
ent (
or N
/A):
____
____
____
_
Appr
oval
Bas
ed O
n:
� Fo
od S
tam
ps /
TAN
F C
ase
Num
ber
� H
ouse
hold
Siz
e an
d In
com
e �
Oth
er _
____
____
Verif
icat
ion
Res
ults
: �
No
Cha
nge
� Fr
ee to
Red
uced
�
Free
to P
aid
� R
educ
ed to
Fre
e �
Red
uced
to P
aid
Rea
son
for C
hang
e:
� In
com
e:__
____
____
____
__
� H
ouse
hold
Siz
e: _
____
____
�
Cha
nge
in F
ood
Stam
ps /T
ANF
� D
id n
ot re
spon
d �
Oth
er: _
____
____
____
____
Dat
e N
otic
e of
Cha
nge
Sent
:___
____
___
Dat
e C
hang
e M
ade:
____
____
_
Req
uest
for A
ppea
l D
ate
Hea
ring
Req
uest
ed:_
____
____
____
____
H
earin
g D
ecis
ion:
___
____
____
____
____
____
Verif
ying
Offi
cial
's S
igna
ture
:___
____
____
____
____
____
____
____
____
____
____
____
_ D
ate:
____
____
____
____
____
____
___
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