Activity Fee Waiver Request Form
Student Information
Student Name
*
First Name
Last Name
Age:
*
Please Select
12
13
14
15
16
17
18
Grade Level:
*
Please Select
7
8
9
10
11
12
School Name:
*
Parent/Guardian Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Email
*
example@example.com
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Event Information
Event Name:
*
Event Date
*
-
Month
-
Day
Year
Date
Participation Fee Amount:
*
Enter dollar amount
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Continue
Continue
Reason for Waiver Request
*
Please provide a brief explanation of why you are requesting a fee waiver. (Examples may include financial hardship, unemployment, unexpected expenses, or other circumstances.)
Certification & Signature
I certify that the information provided above is accurate and that my child could not participate in this event without financial assistance.
Parent/Guardian Signature:
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
For Internal Use Only
Approval:
Reviewed By:
Date of Approval:
Additional Notes:
Should be Empty: