SHARING INFORMATION WITH OTHER PROGRAMS FOR SCHOOL YEAR 2021-22
To save you time and effort, the information you gave on your Free and Reduced Price School Meals Application may be shared with other programs for which your children may qualify. For the following programs, we must have your permission to share your information. Completing and submitting this form will not change whether your children get free or reduced price meals.  For more information, contact the School Nutrition Office at 920-662-7723 or e-mail Jill Stordeur, School Nutrition Secretary, at jillstor@hssdschools.org.
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Yes! I DO want information from my Free and Reduced Price School Meals application shared with the selected below.
The fee secretary for the waiver of student and technology insurance fees.
The fee secretary and high school counselor for the waiver of fees for AP/IB testing, college applications & entrance exams. (ONLY FOR BAY PORT STUDENTS)
The Giving Tree Pantry to qualify for the food pantry once a month, Holiday Store support, school supplies, and other supports. (Staff will contact you to finalize registration)
YOU MUST SIGN AND RETURN THIS FORM EACH YEAR in order to have fees waived and/or qualify for Giving Tree benefits for the current school year.
By signing this form, you are allowing us to share information for the child(ren) listed. Your information will be shared only with the programs you’ve checked above.
Child's FIRST Name:
Child's LAST Name:
School:
Child's FIRST Name:
Child's LAST Name:
School:
Child's FIRST Name:
Child's LAST Name:
School:
Child's FIRST Name:
Child's LAST Name:
School:
Electronic Signature of Parent/Guardian:
Date Submitted:
MM
/
DD
/
YYYY
Phone Number:
USDA Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
 
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov

This institution is an equal opportunity provider.
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