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'21-22 Household Information Survey
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Please submit (1) form per family.
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* Indicates required question
1. Your First Name
*
Your answer
2. Your Last Name
*
Your answer
3. Public School District of Residence
Your answer
4. Public School Building (the name of the specific grade-level building within the district)
Your answer
For #5, please use the below Household Size and Income Chart. For Household Size, please include all adults and all children. For Annual Income, please include all sources of income for all members of the household.
5. Using the above chart, does your household qualify for Reduced Lunch or Free Lunch?
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Reduced Lunch
Free Lunch
Does not qualify
6. By selecting "I Agree" below, I am certifying that all of the information submitted in this form is true and I considered all sources of income for all members in my household.
*
I agree
(Optional) Questions/Comments:
Your answer
Thank you for your submission!
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