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6. Children’s Racial and Ethnic Identities (Optional) – We are required to ask for information about your child(ren)’s race and ethnicity. This information is important and helps make sure we are fully
serving our community. Responding to this section is optional and does not affect your child(ren)’s eligibility for free & reduced-price meals.
Mark one or more racial identities: American Indian or Alaska Native Asian Mark one ethnic identity:
Black, or African American Native Hawaiian or Other Pacific Islander Hispanic or Latino
White Not Hispanic or Latino
7. Other Benefits – Please check the box in front of the programs that you wish to share your child’s free or reduced price meal status with in order to qualify for a reduction in fees:
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 (Basic Food), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on
Indian Reservations (FDPIR) case number or other FDPIR 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 the 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:
https://www.fns.usda.gov/civil-rights/usda-nondiscrimination-
statement-other-fns-programs, 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 and employer.
Seattle Public School District’s Non-Discrimination Statement:
Seattle Public Schools, SPS, provides Equal Educational Opportunities and Equal Employment Opportunities and does not discriminate in any programs or activities on the basis of sex; race; creed; color;
religion; ancestry; national origin; age; economic status; sexual orientation, including gender expression or identity; pregnancy; marital status; physical appearance; the presence of any sensory, mental or
physical disability; honorably discharged veteran or military status; or the use of a trained dog guide or service animal. SPS also provides equal access to the Boy Scouts and other designated youth groups.
Students and Members of the Public with Concerns
For students and members of the public, the following employees have been designated to handle questions and complaints of alleged discrimination: Office of Student Civil Rights, 206-252-0306,
or oscr@seattleschools.org, or by mail at Seattle Public Schools, MS 32-149, P.O. Box 34165, Seattle, WA 98124-1166. In that department:
Sex Discrimination Concerns: For sex discrimination concerns, including sexual harassment, contact: Title IX Coordinator, 206-252-0367, or Title.IX@seattleschools.org
Disability Discrimination Concerns: For disability discrimination concerns contact: Office of Student Civil Rights, 206-252-0306, or accessibility@seattleschools.org
Event Fees Field Trips Advanced Placement Tests Running Start Books Athletic Fees Associated Student Body (ASB) Fees
Pre-College Exams (PSAT/SAT/ACT) College Application Fees
By signing below, I allow the information contained on this application to be shared with the other program(s) I have indicated.
______________________
Parent/Guardian Signature Date
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