Form 124 - Sharing Information With Medicaid Or Nj Familycare Page 2
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1
2Form #124
Revised 5/17
SHARING INFORMATION WITH OTHER PROGRAMS
Dear Parent/Guardian:
To save you time and effort, the information you gave on your Free and Reduced Price School Meals
Application may be shared with other programs for which your children may qualify. For the following
programs, we must have your permission to share your information. Sending in this form will not
change whether your children get free or reduced priced meals.
No! I DO NOT want information from my Free and Reduced Price School Meals Application
shared with any of these programs.
Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with SAT/ACT/AP Waiver Programs and RCBC for CAP credit
Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with Local and National Scholarship Programs
Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with Northern Food and Clothing Drive Programs
Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with Northern Extra/Curricular Programs
Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with NCAA Clearinghouse Fee Waiver Programs
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: ___________________________
School: ________________________
Child’s Name: ___________________________
School: ________________________
Child’s Name: ___________________________
School: ________________________
Signature of Parent/Guardian: ______________________________
Date: __________
Printed Name: __________________________________________________________
Address: ______________________________________________________________
For more information, you may call Mrs. Razzano at 609-298-3900, extension 2069,
or email
Return this form to:
Northern Burlington County Regional School District
160 Mansfield Road East, Columbus, NJ 08022
with your Free and Reduced Price School Meals Application
(over please)
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Parent category: Medical