3436 Edgewood Drive Ashtabula, Ohio 44004 Telephone: 440/998-4411 Fax: 440/992-8369 PATRICK E. COLUCCI, SR., SUPERINTENDENT JAMIE DAVIS, TREASURER

DOCUMENTS NEEDED TO REGISTER YOUR CHILD:

Your child's –

Birth certificate (acceptable: hospital/baptismal certificate) Immunization Record (Baby Shots) Prior School Information (School Name, Address, Phone & Fax Number) If your child has an IEP (Individualized Education Plan) and ETR (Evaluation Team Report)

from his/her prior school, please provide this at the time of registration.

Custodial Parent/Legal Guardian –

Photo ID Proof of residency (One required):

1. Mortgage statement, current lease/rental agreement or utility bill (within the past 30 days) in your name OR

2. If you are living with relatives/friends/others, then the (A) Statement of Residency Affidavit must be completed and notarized and (B) a mortgage statement, lease/rental agreement or current utility bill (within the past 30 days) in the name of the relative/friend/other that you are residing with must be presented. Both A & B must be completed.

NOTE: A Change of Address letter/form from the post office is NOT acceptable proof of residency.

If child is not living with both parents due to a divorce/dissolution or has been placed with a temporary guardian, grandparent or foster home, the following documents MUST be provided

at the time of registration:

Divorce, Dissolution and/or Custody documents filed with the Court designating who is residential parent/legal custodian – Documents must be date stamped and signed by the judge/magistrate.

NOTE: Court Ordered Child Support paperwork is NOT acceptable for proof of custody.

If the parent/guardian cannot provide ALL of the above documentation during registration, the child’s registration may be refused or delayed until proper

documentation is received.

Buckeye Board of Education: Mary Wisnyai (President), Shannon Pike (Vice-President), Gregory Kocjancic, Tina Stasiewski, David Tredente

BUCKEYE LOCAL SCHOOL DISTRICT Student Registration Form

Complete ALL AREAS on both pages of the form.

• Edgewood High • Wallace H. Braden Middle • Kingsville Elementary • Ridgeview Elementary

www.buckeyeschools.info

Office Use Only Grade Level

Building

Admission Date

Admission Code

Student Legal Last Name Student First Name Student Middle Name Nick Name

Student STREET Address (House Number, Street Name, Apartment Number, City, State, Zip Code)

Date of Birth

Gender: Female Male Grade

Last Preschool/School Attended (include Address, City and Zip): Date Withdrew:

Has child ever attended a Buckeye Local School District Building? If yes, building and year last attended. Is the student enrolling as Open Enrollment from another district? Yes No

If Yes, School District’s name: ________________________________________

Citizenship: USA Other

Place of Birth (City AND State):

Special Education Student currently has an IEP (Individualized Education Plan) Yes No If Yes, please submit a copy of the IEP at the time of registration. Student previously received special education services? Yes No If Yes, grade and year the IEP was terminated: Special education services received in previous school district? Yes No Speech/Language Occupational Therapy Physical Therapy Academic Other: Was student under a 504 Plan in previous school district? Yes No If Yes, submit a copy of the 504 Plan at the time of registration. Does your child have any medical condition? Yes No Does your child take any prescribed medication? Yes No Gifted Education Student currently has a WEP (Written Education Plan) or WAP (Written Acceleration Plan) Yes No If Yes, please submit a copy of the WEP or WAP at the time of registration. Parent/Guardian Information Custody of Student/Student lives with: (Please check ONE)

Mother & Father Mother Mother & Stepfather Father Father & Stepmother Other-Cirlce One (Mother & Boyfriend, Father & Girlfriend, Foster Parent(s)/Guardian/Grandparents)

Parent/Guardian 1 Parent/Guardian 2

Name (Last, First)

Mailing Address/PO Box

City/State/Zip

Home Phone (_____) - _____________________

(_____) - _____________________

Cell/Pager No. (_____) - _____________________

(_____) - _____________________

Email Address Relationship to student (Mother, Father, Step Parent, Guardian etc.)

Please circle one: Married Divorced Single Married Divorced Single Siblings in Buckeye Local Schools Name Grade School Name of other adult living with custodial parent:

Relationship

NOTE: If the child is NOT living with both parents, you must provide a time-stamped, Judge/Magistrate signed copy of the temporary or permanent Order/Decree allocating parental rights and responsibilities and/or a time-stamped, Judge/Magistrate ordered copy of any future modification Order. If no Order is available because of pending legal action, a notarized letter stating the date of court proceedings from your attorney must be presented along with the time-stamped copy of the pending court paperwork. If you are not a parent and are in the process of obtaining custody, you must present a notarized statement from your attorney along with the time-stamped copy of the pending court paperwork showing that you are an adult legal resident of the district and have begun legal measures for custody of the child. 1. Please indicate if you have shared or joint custody: Yes No 2. If Yes, who is designated residential parent and legal custodian for educational purposes: ________________ 3. Please indicate if you and other biological parent were ever married: Yes No

□ I hereby certify that, under the penalties of perjury, the facts and representations set forth in this Student

Registration Form are, to the best of my knowledge, true and complete. I also understand the Buckeye Local School District reserves the right to make additional inquiries into the student’s residency status and prior school records.

□ I will notify the school immediately if there is a change of address, phone number or custody.

_____________________________________ _______________________ Parent/Guardian Signature Date _____________________________________ Print Parent/Guardian Name

Ethnicity Questionnaire Per United States Department of Education requirements, when collecting race/ethnicity information

districts must collect this information by using a two part question found below. Student Name Birth Date _____/_____/_____ Part 1: ETHNICITY Is the student Hispanic/Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race): Yes No Regardless of whether you answer Yes or No to Part 1, you MUST also select one or more racial groups in Part 2. Part 2: RACIAL GROUP Is the student from one or more of the following racial groups (check all that apply): _____ (W) White

People who have origins in any of the original peoples of Europe, North Africa, or the Middle East. _____ (B) Black or African American Persons having origins in any of the black racial groups in Africa. _____ (A) Asian Persons having origins in any of the original peoples of the Far East, Southeast Asia, or The Indian subcontinent. This area includes, for example, Cambodia, China, India, Japan, Korea,

Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. _____ (I) American Indian or Alaskan Native Persons having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. _____ (P) Native Hawaiian or Other Pacific Islander Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. _____ PARENT OR GUARDIAN REFUSES TO LIST CHILD’S ETHNICITY AND RACIAL GROUP

I (parent or guardian) refuse to designate the ethnicity of my child and understand that the school district is required by the United States Department of Education to determine the ethnicity of my child based on their observation of the student.

Parent or Guardian Signature Date _____/_____/_____

FOR SCHOOL USE ONLY WHEN PARENT REFUSES TO LIST CHILD’S ETHNICITY AND RACIAL GROUP ABOVE School District’s determination of child’s ethnicity based on observation: _____ Hispanic/Latino _____ White _____ Black or African American

_____ Asian _____ American Indian or Alaskan Native _____Native Hawaiian or Other Pacific Islander

Name of School District employee determining child’s ethnicity (please print) Employee Signature: Date:_____/_____/_____

3436 Edgewood Drive Ashtabula, Ohio 44004 Telephone: 440/998-4411 Fax: 440/992-8369 PATRICK E. COLUCCI, SR., SUPERINTENDENT JAMIE DAVIS, TREASURER

NOTARIZED STATEMENT OF RESIDENCY

(COMPLETE ONLY IF LIVING WITH A FRIEND/RELATIVE/OTHER)

If you and your family are living with a friend/relative/other within the Buckeye Local School District, BOTH you and the person you are living with must: (1) Complete this ENTIRE form, (2) have it NOTARIZED, and

(3) the person you are living with MUST provide a mortgage statement, lease/rental agreement, utility bill (within the past 30 days), current home owner’s or renter’s insurance declaration page, current real property tax bill, paycheck or paystub that includes address of residence or most current available bank statement that includes the address of residence prior to student enrollment: I, _________________________ (Print Property Owner Name), of _________________________________

(Print Property Owner Address), state that ___________________________________________________

(Print Names of ALL people living in your residence) reside with me at the address above.

***I (Property Owner) have provided a mortgage statement, lease/rental agreement or current utility bill

(within the past 30 days) in my name. THIS IS REQUIRED.***

TO BE COMPLETED & SIGNED IN PRESENCE OF NOTARY PUBLIC

On this ______day of_______________, 20____, before me, ____________________________, the

undersigned Notary Public, personally appeared ___________________________________ and

_____________________________________, and proved to me on the basis of satisfactory evidence to be

the persons whose names are subscribed to below and acknowledged to me that they executed the same for

the purpose herein stated.

________________________________________ ____________________________________

Owner of Above-Name Property Signature Date

________________________________________ ____________________________________ Parent/Guardian’s Signature Date

________________________________________ ____________________________________ Notary Public Signature Date My Commission expires:____________________ Place Notary Seal Here

Buckeye Board of Education: Mary Wisnyai (President), Shannon Pike (Vice-President), Gregory Kocjancic, Tina Stasiewski, David Tredente

Ohio I Department of Education

Appendix A: Language Usage Survey

Parents and Guardians: Please only complete this page of the survey. The back of this form will be completed by the school. A completed language usage survey is required for all students upon enrollment in Ohio schools. This information will tell school staff if they need to check your child’s proficiency in English. Answers to these questions ensure your child receives the education services to succeed in school. The information is not used to identify immigration status.

Student Name: (First Name and Last Name) Student Date of Birth: (mm/dd/yyyy)

Communication Preferences Indicate your language preference so we can provide an interpreter or translated documents at no cost when you need them. All parents have the right to information about their child’s education in a language they understand.

1. In what language(s) would your family prefer to communicate with the school?

_____________________________________________________________

Language BackgroundInformation about your child’s language background helps us identify students who qualify for support to develop the language skills necessary for success in school. Testing may be necessary to determine if language supports are needed.

2. What language did your child learn first?

_____________________________________________________________

3. What language does your child use the most at home?

_____________________________________________________________

4. What languages are used in your home?

_____________________________________________________________

Prior Education Responses about your child’s birth country and 5. In what country was your child born? _______________________________ previous education give us information about the knowledge and skills your child is bringing to school and may enable the school to receive

6. Has your child ever received formal education outside of the United States? � Yes � No

additional funding to support your child. If yes, how many years/months? _____________________

If yes, what was the language of instruction? _____________________

7. Has your child attended school in the United States? � Yes � No

If yes, when did your child first attend a school in the United States?

_______ / _______ / __________ Month Day Year

Additional Information Please share additional information to help us understand your child’s language experiences and educational background.

Parent/Guardian First Name: ___________________________ Parent/Guardian Last Name: _____________________________

Parent/Guardian Signature: ____________________________ Today’s Date: (mm/dd/yyyy) _______________________________

Thank you for providing the information above. Contact your school or district office if you have questions about this form or about services available at your child’s school. Translated information about schools’ civil rights obligations to English learner students and limited English proficient parents can be found here: https://www2.ed.gov/about/offices/list/ocr/ellresources.html

ByOffice of Superintendent of Public Instruction, licensed under a Creative Commons Attribution 4.0 International License.

Ohio I Department of Education

(Appendix A, continued)

***COMPLETED BY SCHOOL EMPLOYEE***

1. Check. Confirm the following statements related to the administration of Ohio’s language usage survey:

□ The district or school presented the language usage survey, to the extent practicable, in a language and form that the parent or guardian understood.

□ The district or school informed the parent(s) or guardian(s) of the form’s purpose. The language usage survey only is used to understand students’ linguistic experiences and educational background.

□ The district or school reports information from the language usage survey in the appropriate Educational Management Information System (EMIS) records.

□ For students enrolling from other U.S. schools and districts, school officials request previous language survey data and refer to the information when identifying English learners.

□ Results of the language usage survey are kept with the student’s cumulative records and follow the student if he/she transfers to another district or school.

2. Note. Record additional information to assist the review of the language usage survey.

3. Record. Indicate responses from the language usage survey in the table below. Refer to the Language Usage Survey Annotations on page 2 for item-specific guidance.

Student’s native language See Language Usage Survey Question 2. Report for all students in EMIS.

__________________________________________

Student’s home language See Language Usage Survey Question 3. Report only for English learners in EMIS.

__________________________________________

Potential English learner See Language Usage Survey Questions 2-4.

□ Yes. Assess the student’s English proficiency. □ No. Do not assess the student’s English proficiency.

Immigrant student status See Language Usage Survey Questions 5-7. Report for all students in EMIS.

□ Yes, the student is an immigrant child. □ No, the child is not an immigrant child.

4. Validate. Complete the information below.

_______________________________________ Signature of validating school employee

________________________________ Date (mm/dd/yyyy)

_______________________________________ Printed name of validating school employee

________________________________ Name of school or school district

BUCKEYE LOCAL SCHOOL DISTRICT EMERGENCY MEDICAL AUTHORIZATION FORM

School Year ________________ PLEASE PRINT CLEARLY: CHILD'S NAME ____________________________________________ Last First Middle

ADDRESS _______________________________________________

CITY/STATE/ZIP __________________________________________

BIRTH DATE __________________ GRADE _____ TEACHER _____________________________ CONTACT THE FOLLOWING IN CASE OF EMERGENCY COMPLETE ALL SPACES Include area code for all phone numbers

1. _____________________________________ 2. ______________________________________

Parent / Guardian Mother Parent / Guardian Father

_____________________________________ ______________________________________ Home Phone Business Phone Cell Phone Home Phone Business Phone Cell Phone

_____________________________________ ______________________________________ Name of Business Work Hours Name of Business Work Hours

3. _____________________________________ 4. ______________________________________

Name / Relationship to Child Name / Relationship to Child

_____________________________________ ______________________________________ Home Phone Business Phone Cell Phone Home Phone Business Phone Cell Phone

_____________________________________ ______________________________________ Name of Business Work Hours Name of Business Work Hours

5. TO GRANT CONSENT: In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for

the administration of any treatment deemed necessary by the physicians below or, if they are not available, by another licensed physician or dentist. I give my consent for my child to be transferred to the hospital below or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity of such surgery, are obtained prior to the performance of such surgery. Facts concerning my child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: _______________________________________________________________________________ ______________________________________________________________________________________________________

_____________________________________________ ___________________________________________________ Preferred Physician Phone Number Preferred Dentist Phone Number

_____________________________________________ Preferred Hospital Phone Number

________________________________________________ __________________________________________________

Signature of Parent / Guardian Date

6. TO REFUSE CONSENT: (Fill out ONLY if you have not completed #5 above) I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency

treatment, I wish the school authorities to take no action or to _____________________________________________________

______________________________________________________________________________________________________

________________________________________________ __________________________________________________ Signature of Parent / Guardian Date

Rev. 12/10/18

PURPOSE - To enable parents and guardians to authorize emergency treatment for children who become ill or injured while under school authority when

parents or guardians cannot be reached.

*THIS FORM IS REQUIRED!

Please return by the next

school day.

BUCKEYE LOCAL SCHOOL DISTRICT STUDENT MEDICAL HISTORY UPDATE

CHILD'S NAME _______________________________________________ GRADE _______ AGE _______

Please check the appropriate boxes if your child experiences the following: _____ Allergies - Please list ________________________________________________________________

What happens? _________________________________________________________________________

*Treatment for reaction? __________________________________________________________________

Is Epi-pen prescribed for allergy? Yes No (circle). If yes, parent needs to provide Epi-pen.*

_____ Bee sting allergy - What happened? ____________________________________________________

Is Epi-pen prescribed? Yes No (circle). If yes, parent needs to provide Epi-pen.*

_____ Asthma - Is inhaler or nebulizer used? (circle which applies) *How often? _______________________

List asthma medications __________________________________________________________________

Doctor and Phone number ________________________________________________________________

_____ Diabetes - Type 1 or Type 2 (circle which applies)

Doctor and Phone number ________________________________________________________________

*Treatment: _____ Oral medication (pills)

_____ Insulin injections

_____ Insulin pump

_____ Epilepsy/Seizures - What type? ________________________________________________________

Last seizure ____________________________________________________________________________

Medication taken ________________________________________________________________________

Will child need medication at school? Yes No (circle). If yes, parent needs to provide.*

_____ Any other condition (please explain) ____________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

_____ None of the above, my child is healthy and has no medical problems

*Any medication taken at school requires a medication form to be completed and returned along with physician orders before any

medication can be dispensed at school. This includes over-the-counter medication and self-caring inhalers and Epi-pens. This form is available on our website or can be obtained from the school office or school nurse. The disclosure of student health information within the school is limited to information necessary to serve the student’s health and educational interest. Your signature is an informed consent to share health history information with staff/personnel of the Buckeye Local School District.

Parent MILITARYSERVICE Information – Please report if either parent or guardian is currently serving in any branch of the Military. Please answer for Mother and Father or current legal guardian:

_______________________________________ _____________________________ Parent/Guardian Signature Date

Rev. 12/10/18

Mother/Guardian Father/Guardian

1. Are you currently serving in the U.S. Military?

If yes, please continue to question 2.

__Y __N

__Y __N

2. What is your current status? Active Reserves

The Guard

FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE SCHOOL MEALS

Dear Parent/Guardian: Children need healthy meals to learn. Buckeye Local Schools offers healthy meals every school day. Breakfast costs 1.60; lunch costs $2.75 K-5 & 6-12 $2.90. Your children may qualify for free meals or for reduced price meals. Reduced price is $.30 for breakfast and $.40 for lunch. This packet includes an application for free or reduced price meal benefits, and a set of detailed instructions. Below are some common questions and answers to help you with the application process.

1. WHO CAN GET FREE OR REDUCED PRICE MEALS? • All children in households receiving benefits from the supplemental nutrition assistance program

(SNAP) or Ohio Works First (OWF) are eligible for free meals. • Foster children that are under the legal responsibility of a foster care agency or court are

eligible for free meals. • Children participating in their school’s Head Start program are eligible for free meals. • Children who meet the definition of homeless, runaway, or migrant are eligible for free meals. • Children may receive free or reduced price meals if your household’s income is within the limits on

the Federal Income Eligibility Guidelines. Your children may qualify for free or reduced price meals if your household income falls at or below the limits on this chart. Please note this is for 2018-19 school year and will be adjusted July 2019.

2. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does your family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and haven’t been told your children will get free meals, please call or e-mail Buckeye Local Schools 3436 Edgewood Drive, Ashtabula, Ohio 44004 (440)-998-4411.

3. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: Lisa Loomis, 3436 Edgewood Drive, Ashtabula, Ohio 44004 (440)-990-3162.

4. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you got carefully and follow the instructions. If any children in your household were missing from your eligibility notification, contact Lisa Loomis, 3436 Edgewood drive, Ash. Oh 44004 (440)-990-3162, l.loomis@buckeyeschools.info immediately.

5. CAN I APPLY ONLINE? At this time there is no online application for this district.

FEDERAL ELIGIBILITY INCOME CHART For School Year 2018-2019

Household size Yearly Monthly Weekly

1 $22,459 $1,872 $432 2 30,451 2,538 586 3 38,443 3,204 740 4 46,435 3,870 893 5 54,427 4,536 1,047 6 62,419 5,202 1,201 7 70,411 5,868 1,355 8 78,403 6,534 1,508 Each additional person: 7,992 666 154

6. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year, through [date]. You must send in a new application unless the school told you that your child is eligible for the new school year. If you do not send in a new application that is approved by the school or you have not been notified that your child is eligible for free meals, your child will be charged the full price for meals.

7. I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please send in an application.

8. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report.

9. IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.

10. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to: Lisa Loomis, (440)-990-3162, l.loomis@buckeyeschools.info

11. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. citizens to apply for free or reduced price meals.

12. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.

13. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.

14. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Any additional combat pay resulting from deployment is also excluded from income.

15. WHAT IF THERE ISN’T ENOUGH SPACE ON THE APPLICATION FOR MY FAMILY? List any additional household members on a separate piece of paper, and attach it to your application. Contact Lisa Loomis, (440)-990-3162 to receive a second application.

16. Why am I being asked about giving my consent for an instructional fee waiver? Ohio public schools are required to waive the school instructional fees for children who quality for free meal benefits. School Food Service personnel must have parent consent to share student meal application if your child(ren) quality for a fee waiver. If you agree to allow your child(ren)’s meal application to be shared with school officials to see if he/she/they qualifies for a fee waiver then check “yes” in part 5. If you do not wish for that information to be shared, then check “no” in part 5. Answering no to this question will mean your child will not be able to be considered for a fee waiver. Answering this question either way will not change whether your child(ren) will get free or reduced price meals.

17. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for Ohio SNAP or other assistance benefits, contact your local assistance office or call 877-852-0010.

If you have other questions or need help, call (440)-990-3162. Sincerely, LISA LOOMIS

Buckeye 2019-2020 FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION

Part 1. ALL HOUSEHOLD MEMBERS

Names of all household members (First, Middle Initial, Last)

Name of school and school grade level for each child/or indicate “NA” if child is not in school. School Grade

Check if a foster child (legal responsibility of welfare agency or court) *If all children listed below are foster children, skip to Part 5 to sign this form.

Check if No

Income

Part 2. BENEFITS: If any member of your household receives Supplemental Nutrition Assistance Program (SNAP) or Ohio Works First (OWF) benefits, provide the name and 10-digit case number for the person who receives benefits and skip to Part 5. If no one receives these benefits, skip to Part 3. NAME: ____________________________________________ 10-DIGIT CASE NUMBER:___________________________________________ Part 3. If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call Buckeye Local Schools (440)-998-4411. Homeless Migrant Runaway

Part 4. TOTAL HOUSEHOLD GROSS INCOME (before deductions). List all income on the same line as the person who receives it. Check the box for how often it is received. Record each income only once.

1. NAME (List all household members with income)

2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVED

Earnings from work

before deductions W

eekl

y Ev

ery

2 W

eeks

Tw

ice

Mon

thly

M

onth

ly Welfare,

child support, alimony W

eekl

y Ev

ery

2 W

eeks

Tw

ice

Mon

thly

M

onth

ly

Pensions, retirement,

Social Security, SSI, VA benefits

Wee

kly

Ever

y 2

Wee

ks

Twic

e M

onth

ly

Mon

thly

All Other Income (indicate frequency,

such as “weekly” “monthly” “quarterly”

“annually”

(Example) Jane Smith $200 $150 $0 $50.00/quarterly__ $ $ $ $________/_______

$ $ $ $________/_______

$ $ $ $________/_______

$ $ $ $________/_______

$ $ $ $________/_______

Part 5. SCHOOL INSTRUCTIONAL FEE WAIVER ADULT CONSENT: Your child(ren) may qualify for a waiver of their school instructional fees. We must have your permission to share your meal application information with school officials if your child(ren) qualifies for a fee waiver. Answering this question will not change whether your children will get free or reduced price meals. Please check a box: Yes I agree to have my meal application used to determine if my child(ren) qualify for a fee waiver.

No, I do not agree to have my meal application used to determine if my child(ren) qualify for a fee waiver.

Signature of Parent/Guardian for the Instructional Fee Waiver Question: _____________________________________ Date: ________________

Part 6. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN) An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the back of this page.)

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that deliberate misrepresentation of the information may cause my children to lose meal benefits and I may be subject to prosecution under State and Federal statutes. Sign here: X________________________________________Print name:______________________________________Date: ______________

Address:_______________________________________________________________________Phone Number:_________________________

Last four digits of your Social Security Number: __ __ __ __ I do not have a Social Security Number

Part 7. Children’s ethnic and racial identities (optional) Choose one ethnicity: Choose one or more (regardless of ethnicity):

Hispanic/Latino Not Hispanic/Latino

Asian American Indian or Alaska Native Black or African American White Native Hawaiian or other Pacific Islander Don’t fill out this part. This is for school use only.

Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12 Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year Household size: ________ Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Reason: ____________________ Determining/Approval Official’s Signature: _____________________________________________________ Date: _____________________ Confirming Official’s Signature: _____________________________________________________________ Date: _____________________ Follow-up Official’s Signature: ______________________________________________________________ Date: _____________________ If selected for Verification, Date Verification Notice Sent:_________ Response Date: _________ 2nd Notice Sent: ________ Results Sent:_______ Verification Result: No Change _____ Free to Reduced Price _____ Free to Paid _____ Reduced Price to Free ____ Reduced Price to Paid ___

Privacy Act Statement: This explains how we will use the information you give us. The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The last four digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Ohio Works First (OWF) case number or other identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. 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: mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 fax: (202) 690-7442; or email: program.intake@usda.gov. This institution is an equal opportunity provider.