EmailMe Form - 2026-2027 Household Economic Survey

Please enter the number of people in your household, including all children and adults. *

Please enter the total annual income for all people in the household before any deductions for taxes, insurance, medical expenses, child support per year. *

$ Dollars . Cents

Student Information

	Student Name	School	Grade	Date of Birth
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You DO NOT have to complete this form to get reduced price or free Child Nutrition Program benefits for your children. If you do not agree to 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.

By selecting “NO” you agree to pay full price enrollment and technology fees.

Consent for Disclosure *

Enrollment Fees *

Textbook/Technology Fees *

I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive federal and state funding based on the information provided. I understand that school officials may verify (check) the information.

Signature of Parent or Guardian *

First Last

Date Time *

MM / DD / YYYY

Phone

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