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Geibel Catholic Junior-Senior High School

Family Survey 2020-2021

Dear Parents:

Federal programs provide essential services to students in non-public schools. Your federal tax dollars can be used by non-public schools to provide materials, services and programming.  To receive the maximum amount of tax dollars for Geibel Catholic Junior-Senior High School, it is essential that you complete the survey available on our website under “Family Resources – School Forms”.   The return of these surveys is required before these critical funds can be awarded.

I want to assure you that all information will be kept confidential.  Only total numbers that represent the whole school are communicated to the federal programs.

Please complete the form by Friday, September 20.  Do not hesitate to call me if you have any questions about the survey.

Thank you for your assistance.

Sincerely,

Patricia Nickler
Principal

First Parent/Guardian's Name

First Name*

Last Name*
First Parent/Guardian's Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian's Signature*
Second Parent/Guardian's Name

First Name*

Last Name*
Second Parent/Guardian's Date of Birth*
Third Parent/Guardian's Name

First Name*

Last Name*
Third Parent/Guardian's Date of Birth*
Fourth Parent/Guardian's Name

First Name*

Last Name*
Fourth Parent/Guardian's Date of Birth*
Fifth Parent/Guardian's Name

First Name*

Last Name*
Fifth Parent/Guardian's Date of Birth*
Sixth Parent/Guardian's Name

First Name*

Last Name*
Sixth Parent/Guardian's Date of Birth*
Seventh Parent/Guardian's Name

First Name*

Last Name*
Seventh Parent/Guardian's Date of Birth*
Eighth Parent/Guardian's Name

First Name*

Last Name*
Eighth Parent/Guardian's Date of Birth*
Ninth Parent/Guardian's Name

First Name*

Last Name*
Ninth Parent/Guardian's Date of Birth*
Tenth Parent/Guardian's Name

First Name*

Last Name*
Tenth Parent/Guardian's Date of Birth*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Family Information

Find your family size and the annual gross income level listed beside it on the chart printed below

Family Size     Annual Rate
1*                     $ 23,606
2                       $ 31,894
3                       $ 40,182
4                       $ 48,470
5                       $ 56,758
6                       $ 65,046
7                       $ 73,334
8                       $ 81,622

For each additional family member add +$ 8,288

*This may be a foster child, an emancipated youth, or a special education child over age 18.

Note:  If you are paid on a weekly or monthly basis, please multiply that amount into an annual figure for comparison based on the weeks or months you actually work each year.

Is your annual income equal to or less than this amount? (Please reference the Family Size/Annual Rate chart above)
Is your family eligible for food stamps?
Are you receiving TANF Cash Assistance? (Formerly AFDC or Public Assistance)
Are any of your children eligible to receive medical assistance under the Medicaid program?
We have not answered any of the above questions because we do not wish to share this information in writing.*

Family Name *

# of family members *

Address (home location, not mailing) *

Public school district in which you reside: *
Child 1 Information

Full Name *

Grade Level *

Public school building the child would attend if you had not chosen our school: *
Child 2 Information (if applicable)

Full Name

Grade Level

Public school building the child would attend if you had not chosen our school:
Child 3 Information (if applicable)

Full Name

Grade Level

Public school building the child would attend if you had not chosen our school:
Child 4 Information (if applicable)

Full Name

Grade Level

Public school building the child would attend if you had not chosen our school:
Child 5 Information (if applicable)

Full Name

Grade Level

Public school building the child would attend if you had not chosen our school:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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