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Participation Agreement

Please read teh following conditions for participation and CHECK EACH BOX to indicate your agreement.

If you do not agree to ALL of the following conditions, do not submit the application.

Child's Information
Primary Contact Information (Mother or legal guardian)
Secondary Contact Information (Father)
Additional Factors
  • Child was born to a teenage mother
  • Child exposed to substance abuse (drug or alcohol)
  • Child exposed to physical abuse or domestic violence
  • Child exposed to stressful life events (death of a parent, chronic illness of parent of sibling, mental health/illness)
  • Child lives in a neighborhood with high violence/crime
  • Parent is or recently has been incarcerated
  • One of both parents has low reading ability
  • Family has moved one or more times in the last year
  • Child is now or has recently been in foster care
  • Child lives in a home with multiple families in the same household
Income Information

I certify (promise) that all information on this application is true and that ALL income is reported.  School officials have my permission to verify the information on this application.  I may also be asked to provide full documentation of income, at any time.  I understand that if I give false information or if I do not meet all of the terms of this agreement, my child(ren) will lose these tuition benifits.  I agree to ALL of the conditions listed in the first section, regardless of the number of boxes checked.

Deadline for application submission is August 1, 2018