College of Southern Nevada
Jumpstart Concurrent Enrollment Program
2020/2021 Tuition Financial Assistance - Student Form
Clark County School District
College and Career Readiness and School Choice Department
The cost of 2020/2021 College of Southern Nevada (CSN) Jumpstart Concurrent Enrollment courses is $50 per course
plus an additional technology fee of $8.50 per credit. For students who qualify, tuition cost assistance is available for up
to four CSN Jumpstart college courses (2 per semester). Fee waivers are not guaranteed, financial assistance is
granted on a case by case basis.
If you meet one or more of the guidelines listed below, complete and return this form as soon as possible, but no later
than ___________________________ to the Jumpstart teacher at your school to be considered for assistance with
tuition costs.
Tuition assistance will be provided for students meeting the following criteria (please check one):
❏ I am currently on the Free and Reduced-Price Lunch program and I give permission to share my
eligibility status with staff in charge of the CSN Jumpstart Concurrent Enrollment Program at my
school.
❏ I am not currently on the Free and Reduced-Price Lunch program, but I meet one or more of the
following criteria:
❏ The student is a member of a family whose taxable income for the preceding year did not exceed 185
percent of an amount equal to the poverty level as established by the Bureau of the Census (see table
on page 2).
❏ The student’s family receives assistance under Part A of Title IV of the Social Security Act.
❏ The student is eligible to receive medical assistance under the Medicaid Program under Title XIX of
the Social Security Act.
❏ The student has status as a legally emancipated minor or, in the best judgement of the staff in charge
of the CSN Jumpstart Concurrent Enrollment Program at my school, is entirely responsible for his/own
support and may also have qualified for waiver of other school-related fees such as athletics, program,
or arts participation.
❏ Other, please explain:
Name of Student: Student ID:
School Name Grade Level:
Semester 1 Course Name(s) _____________________________________________________________________
Semester 2 Course Name(s) _____________________________________________________________________
By signing the following form, I agree that the above information is correct. I also give permission to share my
student’s free and reduced-price meal eligibility status with staff in charge of the CSN Jumpstart Concurrent
Enrollment Program at my school.
Student Signature Date:
Parent/Guardian Signature Date:
