Re-Enrollment Form

Re-enrollment Packet

Step 1 of 10

HOUSEHOLD INFORMATION SURVEY FLEX High School is participating in the Community Eligibility Option provision under the National School Lunch Program. Under this option, all children in the school will receive a breakfast/lunch at no charge regardless of completion of this form. However, to determine eligibility for various additional state and federal program benefits that your child(ren)’s school may qualify for, please complete, sign and return this application to your student’s building if your income falls within or below the guidelines listed in the following chart. INCOME GUIDELINES – 185% Guidelines to be effective from July 1, 2021 through June 30, 2022

Persons in Family or Household Size	Annual	Monthly	Twice Per Month	Every Two Weeks	Weekly
1	$23,828	$1,986	$993	$917	$459
2	$32,227	2,686	1,343	1,240	620
3	$40,626	3,386	1,693	1,563	782
4	$49,025	4,086	2,043	1,886	943
5	$57,424	4,786	2,393	2,209	1,105
6	$65,823	5,486	2,743	2,532	1,266
7	$74,222	6,186	3,093	2,855	1,428
8	$82,621	6,886	3,443	3,178	1,589
Each Additional Member Add	$8,399	700	350	324	162

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: [email protected]. This institution is an equal opportunity provider.

If any member of your household receives Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) or Ohio Works First (OWF) benefits, provide the name and 10-digit case number for the person who receives the benefits then proceed to Section 4. If no one receives these benefits, start with Section 1.
Name:
10-digit Case Number
1. These selections must be completed by the Head of Household or Designee
Size of Family*
Please enter a number from 1 to 15.
Indicate the total number of individuals living in your household, including all adults and children.
2. Students Living in the Household
Student information - Complete for each student Pre-K through 12th grade in the household.
Person 1 Name
First Last
Person 1 Birth Date
MM slash DD slash YYYY
Person 1 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 2 Name
First Last
Person 2 Birth Date
MM slash DD slash YYYY
Person 2 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 3 Name
First Last
Person 3 Birth Date
MM slash DD slash YYYY
Person 3 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 4 Name
First Last
Person 4 Birth Date
MM slash DD slash YYYY
Person 4 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 5 Name
First Last
Person 5 Birth Date
MM slash DD slash YYYY
Person 5 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 6 Name
First Last
Person 6 Birth Date
MM slash DD slash YYYY
Person 6 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 7 Name
First Last
Person 7 Birth Date
MM slash DD slash YYYY
Person 7 School
Is this person Homeless, Migrant, Runaway, or Foster?
Person 8 Name
First Last
Person 8 Birth Date
MM slash DD slash YYYY
Person 8 School
Is this person Homeless, Migrant, Runaway, or Foster?
3. Income Information
TOTAL MONTHLY HOUSEHOLD INCOME – Report Income for all members of household excluding foster children. If you have reported a case number above, you do not need to complete this section.
1. Gross Monthly Earnings: Wages, Salary, Commissions
Please enter a number greater than or equal to 0.
Enter 0 if no income.
2. Monthly Welfare Payments, Child Support, Alimony
Please enter a number greater than or equal to 0.
Enter 0 if no income.
3. Monthly Payments from Pensions, Retirement, Social Security
Please enter a number greater than or equal to 0.
Enter 0 if no income.
4. Monthly Dividends or Interest on Savings
Please enter a number greater than or equal to 0.
Enter 0 if no income.
5. Monthly Worker’s Compensation, Unemployment, Strike Benefit
Please enter a number greater than or equal to 0.
Enter 0 if no income.
6. Other Monthly Income (SSI, VA, Disability, Farm, other)
Please enter a number greater than or equal to 0.
Enter 0 if no income.
Total Monthly Household Income (Add lines 1-6)
Enter 0 if no income.
4. Certification
SIGNATURE - If Income Section is completed, the adult signing the form must also list the last four (4) digits of his or her Social Security number or check the “I do not have a Social Security number” box below.
Certification*

I certify (promise) that all information on this application is true and that all income is reported. I understand the school will be eligible for certain federal and/or state funds based on the information I give. I understand that the school officials may verify (check) the information. I understand that if I purposely give false information, my child may lose benefits and I may be prosecuted.
Head of Household or Designee Name*
Head of Household Signature*
Today's Date*
MM slash DD slash YYYY
Last 4 of Social
Check here if you do not have a Social Security Number.
- I do not have a Social Security Number.
Head of Household or Designee Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Email Address

By providing your email address you may be contacted via email by the district.

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Organization	Information To Be Released
Press, television, and other organizations	Information concerning participation in athletics, other school activities, the winning of scholastic or other honors and awards, and other such information.
P.T.A. officers	Names, addresses, and telephone numbers of pupils they represent.
Colleges and Universities	Transcripts, letters of recommendation for admission, scholarships, etc.
Employers or potential employers	Name, address, age, scholastic record, and staff employment recommendation.
Private business or professional schools or colleges approved by the Ohio State Superintendent or Public Instruction	Names and addresses of graduating seniors.
Official employment of recruitment representatives of private industry; federal, state, and local government agencies; and the military forces of the United States.	Career guidance information including names and addresses of graduating seniors.
Another school district in which pupil intends to enroll or has enrolled	School records and / or transcript of grades and credit.

Re-enrollment Packet

Step 1 of 10

Parent/ Guardian Information

Court Orders

Special Services Information

Other Information

Student Ethnicity and Race

Previous Schools

Enrollment Continued

Parent/ Guardian/ Caregiver Education Level

Referral Information

Emergency Contacts

Sibling Information

Health Information

Insurance Information

Doctor Information

Previous School Information

2. Students Living in the Household

3. Income Information

4. Certification

Special Education Information

English Language Development Information

Consent to Release Confidential Information

Proof of Residency

Consent

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Re-Enrollment Form

Re-enrollment Packet

Step 1 of 10

Parent/ Guardian Information

Court Orders

Special Services Information

Other Information

Student Ethnicity and Race

Previous Schools

Enrollment Continued

Parent/ Guardian/ Caregiver Education Level

Referral Information

Emergency Contacts

Sibling Information

Health Information

Insurance Information

Doctor Information

Previous School Information

2. Students Living in the Household

3. Income Information

4. Certification

Special Education Information

English Language Development Information

Consent to Release Confidential Information

Proof of Residency

Consent

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