Admission Application Fee Waiver Request
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1Admission Application
Fee Waiver Request
Start Date/Year:
Winter ________
Spring _______
Summer _______
Fall _________
STUDENT: Print the information requested below and then have an Authorized Official sign the Certification
Statement.
__________________________________________________________________________________________
STUDENT FIRST NAME STUDENT LAST NAME
__________________________________________________________________________________________
MAILING ADDRESS CITY STATE ZIP CODE
AUTHORIZED OFFICIAL CERTIFICATION STATEMENT: I certify that the student named above meets the
indicator(s) of economic need checked below. Authorized Officials include a H.S. Principal, Counselor,
Financial Aid Officer or Community Leader.
__________________________________________________________________________________________
Authorized Official’s Name Authorized Official’s Signature
__________________________________________________________________________________________
Name of Educational Institution or Other Organization
__________________________________________________________________________________________
Authorized Official’s Title Phone Number
ECONOMIC NEED: The Student must meet at least one of the following indicators of economic
need (please check under which method the student qualifies).
Student has received or is eligible to receive an ACT or SAT Test fee waiver.
Student is enrolled in or eligible to participate in the Federal Free or Reduced Price Lunch
program (FRPL).
Student is enrolled in a federal, state or local program that aids students from low‐income
families (e.g., TRIO programs such as Upward Bound).
Student’s family receives Public Assistance.
Student is homeless or lives in federally subsidized public housing or a foster home.
Student is a ward of the State or an Orphan.
Other reason from H.S. principal, Counselor, Financial Aid officer, or Community Leader as
indicated below:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
This form can be returned with your Admissions Application or you may fax it to (818) 345‐8153.
If you have questions about completing this form, please call (818) 401‐1294 or (818) 345‐8414.
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