Impact Aid Program Survey Form
The survey date January 11, 2021
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All responses must be filled in with complete information if applicable.
Must fill one out for each student that attends Wayne Preparatory Academy
Student Information
Student's Last Name *
Student's First Name *
Student's Middle Initial *
Date of Birth *
JJ
/
MM
/
YYYY
Grade *
School Name
Wayne Preparatory Academy
Address *
City *
State
NC
Zip Code *
PARENT/GUARDIAN EMPLOYMENT INFORMATION: CIVILIAN
Enter information in this section regarding parent/guardian if 1) neither parent/guardian with whom the student resided was on active duty in the Uniformed services of the United States AND 2) either parent/guardian with whom the student resided was employed on federal property OR 3? either the parent/guardian reported to work on federal property on the survey date. Enter the parent/guardian's name as it appears on the employer's payroll record.
Parent/Guardian's Last Name
First Name and Middle Initial
Name of Parent/Guardian's Employer
Address of Parent/Guardian's Employer
City
State
Zip Code
Name of Federal Property
Address of Federal Property
City
State
Zip Code
PARENT/GUARDIAN EMPLOYMENT INFORMATION: UNIFORMED SERVICES
Enter information in this section regarding the parent/guardian if either person was on active duty in the Uniformed  Services of the United States on the survey date.
Parent/Guardian's Last Name
First Name and Middle Initial
Branch of Service
Rank
PARENT/GUARDIAN EMPLOYMENT INFORMATION: FOREIGN MILITARY
Enter information in this section regarding the parent/guardian if either person was both an accredited foreign government official and a foreign military officer on the survey date.
Parent/Guardian's Last Name
First Name and Middle Initial
Branch of Service
Rank
Name of Foreign Government
This information is the basis for payment to your school district of federal funds under the Impact Aid Program (Title VIII of the Elementary and Secondary Education Act), and may be provided to the U. S. Department of Education if your school district's application for payment is audited. This form must be signed and dated for your school to receive funds based on this information.
By signing this form, I am certifying that all typed and written information on this form is accurate and complete as of the survey date.
Signature of Parent/Guardian
Date
JJ
/
MM
/
YYYY
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