Policy Details

5137.1 FORM Extracurricular Activities Participation Fee

5137.1

FORM

STUDENTS

LITCHFIELD PUBLIC SCHOOLS

CONFIDENTIAL WAIVER FORM

EXTRACURRICULAR ACTIVITIES PARTICIPATION FEE

DATE: __________________

SCHOOL: ___ Center School ___ Intermediate School ___ Middle School ___High School

STUDENT NAME(S) (print) GRADE(S) ACTIVITY FEE(S)

__________________ _________ _________________ $___________

__________________ __________ _________________ $___________

__________________ __________ _________________ $___________


PARENT/GUARDIAN NAME (print): ________________________________

________________________________

Waiver Request: Please describe below the nature of your fee waiver request.

_____ Student(s) receives free or reduced price lunch, the fee is automatically waived.

_____ OTHER – Please describe.

For Office Use Only

Reviewed by: _____________________________ Date: ________________

Building Principal or Designee

Approved or Denied

Parent or guardians please submit completed form to the appropriate school building Principal(s) for review and approval process.

Litchfield Public Schools
Form Adopted: 9/28/2004
Form Revised: 4/10/2018


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