Consent for Disclosure Sharing Information with Other Programs

 

Dear Parent/Guardian:
 

You do not have to sign or send in this form to get reduced price or free Child Nutrition Program benefits for your children.  If you do not sign the Consent for Disclosure, it will not affect eligibility for or participation in the Child Nutrition Programs.
 

To save you time and effort, information about your children’s eligibility for reduced price or free Child Nutrition Program benefits may be shared with other programs for which your children may qualify.  For the programs listed below, we must have your permission to share your information. 

Yes, I DO want school officials to share information about my children’s eligibility for Child Nutrition Program benefits only with the programs I have checked below.

Enrollment Fees

Technology Fees


 

If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the programs you checked.

Child's Name

Signature of Parent/Guardian

Printed Name

Address

School

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Date

For more information, you may call or email:

School Official's Name:  Summer Warren

Phone: 620-235-3250

This institution is an equal opportunity provider.

USD 250 Pittsburg Community Schools | 510 Deill Street | Pittsburg, KS 66762
Phone: 620-235-3100 | Fax: 620-235-3106

    USD 250 CONTINUED LEARNING