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Ascension School - REQUIRED Economic Deprivation Survey for Federal Program Participation

Please complete the form below. Required fields marked with an asterisk *

This information will be kept confidential. It eill be used to determine the amount of federal program services available to the nonpublic school. Please contact your nonpublic school if you need assistance.

INSTRUCTIONS

This form may be used to collect information that can be used to determine the amount of federal program services available to this school. It will be kept strictly confidential.

Section 1: Household and Individual Eligibility Methods: Indicate which method determines household or individual eligibility (foster children cannot extend eligibility to household members). Otherwise, indicate that the household is not eligible.

Section 2: Student Information: List the number of eligible children that attend this nonpublic school and the grade level of each eligible child. This section must be completed for ALL students that meet the eligibility criteria.

Use the following chart to determine if the household is eligible based on income. If the total amount of income of all household members (before taxes or anything else is taken out) exceeds the amount on the chart for your household size, the household is not eligible.

Economic Deprivation

Section 3: Signature: All applications MUST have the signature of an adult household member. All applicatins must also have the physical address of the household.

Section 1

Household Eligibility*

Answer required for "Household Eligibility"

Household is eligible based on receiving food stamps.

Household is eligible based on income (see instructions above).

Household is not eligible.

Individual Eligibility*

Answer required for "Individual Eligibility"

Student is eligible as they are a foster child in the household (see instructions above).

Student is not eligible.

Section 2

Student Information: this must be completed for ALL students that meet the eligibility criteria above.

Number of children that attend this nonpublic school:*

Answer required for "Number of children that attend this nonpublic school:"

Current grade level of each child:*

Answer required for "Current grade level of each child:"

Section 3

Signature - I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of Federal Funds and will be kept confidential at the school.*

Signature Required

Home Address (including city/state/zip)*

Answer required for "Home Address (including city/state/zip)"

Public school district in which you reside (ie. Parkway, Rockwood, etc.)*

Answer required for "Public school district in which you reside (ie. Parkway, Rockwood, etc.)"

If your child is in K-5 (elementary school), name of the public school they would attend:*

Answer required for "If your child is in K-5 (elementary school), name of the public school they would attend:"

If your child is in 6-8 (middle school), name of the public school they would attend:*

Answer required for "If your child is in 6-8 (middle school), name of the public school they would attend:"

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"