Parent Memo August 1st, 2015

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1 Parent Memo August 1st, 2015 Guiding students in becoming responsible lifelong learners and compassionate community members through interdisciplinary studies in the arts and sciences within a safe and nurturing environment MRA Essential Question: How do I impact my environment and how does my environment impact me? School Hours : 7:00 a.m. Before Care Opens (this is a charged service) 7:55 a.m. Students can come into classrooms 8:00 a.m. School starts 2:50 p.m. K-4th Grade Release Monday, Tuesday, Thursday, Friday 3:00 p.m. 5th 8th Grade Release Monday, Tuesday, Thursday, Friday 12:50 p.m. K 4th Grade Release on Wednesdays 1:00 p.m. 5th 8th Grade Release on Wednesdays 6:00 p.m. After School Closes (this is a charged service) Calendar of Events at MRA: MRA Book Swap Come on out and exchange your book for a new one any time. The books are available for swapping under the breezeway outside of the library. Week of August 3rd: Our Pirate Ship will be underway this week! We have hired a contractor to build our ship and hopefully have it complete by the start of school on September 8th. August 6th Work Day 8:30 a.m. to Noon, MRA Workday. Please bring gloves, painting supplies, garden tools, clippers, etc. August 10th 6:30 p.m. Boosters Meeting at Legends, all are welcome August 18th 5:30 p.m. Strategic Planning meeting, all are welcome 6:30 p.m. MRA Board meeting, all are welcome August 24th 6:30 p.m. MRA Auction meeting at Legends, all are welcome August 25th, Work Day 8:30 a.m. to Noon, MRA Workday. Please bring gloves, painting supplies, garden tools, clippers, etc. August 31st to September 4th: Staff Development September 3rd: 6:00/6:30 p.m. Mandatory Back to School Parent Night Back to School Night will be held on September 3rd this year starting at 6:00 p.m. for families new to MRA and 6:30 p.m. for families who attended last year. This is a mandatory parent meeting to get the school year off to the best start possible. We will be introducing you not only to our new teachers and our theme for the year, but also to some exciting changes we are making to lunches at MRA and more! September 7th, Labor Day September 8th, First day of school all students 8:00 a.m. start September 15th, 5:00 p.m. All School BBQ Please make sure to mark your calendars for the MRA back to school BBQ on September 15th starting at 5:00 p.m. This is a great way to reconnect with friends and teachers. October 2nd, Jog-a-thon Important MRA Updates: Emergency Kits We need your help in assembling individual student emergency supply kits for your child as part of our emergency preparedness plan. These kits will be kept at MRA in case of an emergency which would require your child to remain at school for an extended Our Vision Is: Successful graduates with the knowledge and confidence to pursue their dreams and enrich the community.

2 period of time. The personalized kits will be returned to the student at the end of this school year. Everything should be packed in a one gallon heavy-duty ziplock bag with your child's name on it. Some information went out in the July Newsletter. Please watch for more information in the August/September Newsletter due out the middle of August. Safety Committee If you are interested in being on the school safety committee please me at surben@mra-k8.com. This committee will meet in August or September to review our Safety Manual and determine any changes or additions that need to be made. They will meet an additional 3 to 4 times during the school year to walk the facilities and insure that all safety requirements are being met. Lunches Please see the next page for the letter regarding our new school lunch program. To complete a free and reduced lunch application please go to the following website and download the form, or use the form attached to this memo. Please remember that your information will be kept confidential. Only the Executive Director will see your application. hp:// Staff After School Activities Director: Please me at surben@mra-k8.com if you are interested in this position. Hour run from 3:00 to 6:00 Monday, Tuesday, Thursday and Friday; and from 1:00 to 6:00 on Wednesdays. Parent Night, September 3rd at 6:00 p.m./6:30 p.m. Please make sure that the parents or one adult representative of your student/s attends our annual Parent Night. This is a mandatory meeting designed to welcome and introduce you to the upcoming school year. It will give you an opportunity to meet with other families as well as with your child s teacher and much more. Boosters The Boosters team is up and running. We had a great turn out at the first meeting in July. Please join us on August 10th, 6:30 p.m. at Legends for our next meeting and see how you can get involved. Before/AfterCare; Sign up forms will be in your information packet on Parent Night, are included at the end of this memo, and will downloadable from our website. Please make sure you have completed a form prior to using before or aftercare. Fred Meyer Community Awards: We recently heard from Fred Meyer community awards. We had 18 house holds use this program between 4/1/15 and 6/30/15 and we earned $ If you shop Fred Meyer please sign up and help us earn some no-cost-to-you dollars! New Math Program Grades 6 through 8 MRA has adopted a new math program for our 6th to 8th grade students. College Preparatory Mathematics is being successfully used by several schools and districts throughout Oregon. Four of our teachers attended the training this past week in Tigard. We will be introducing this curriculum to parents and students in the fall. Wanted Auction 2016 Chair or Co-Chairs This years auction was a huge success and we have a lot of ideas and folks ready to support our auction next year. Please send me an at surben@mra-k8.com if you are interested in chairing or co-chairing next years auction event. One person indicated an interest in running the auction on our survey form but did not put a name! If it was you, please contact me at surben@mrak8.com. Amazon Smile If you haven t yet, please sign up to use Amazon Smile. Once registered Amazon will prompt you to select Amazon Smile in order for MRA to receive a percentage of any purchase you make. This is an easy, no cost to you way to raise extra money for Molalla River Academy classrooms and teachers. Additional No Cost to You MRA Fundraisers Fred Meyer: NPO number Scrip: Order forms are attached Coke at Escrip at AmazonSmile: Scroll down and choose Molalla River Academy on the donation page. Box Tops for Education sign up online at and bring your box tops in to MRA Safeway link your Safeway card to MRA at

3 School Supplies We will be asking each family to pay $40/student to MRA in lieu of purchasing consumable supplies. Items not included in this fee are backpacks, lunch boxes, calculators, flash drives, water bottles etc. We have increased this amount by $5.00 to eliminate the request for reams of paper. Attachments: escrip renewal information Income Letter Confidential Income Statement English Confidential Income Statement Spanish MRA Before and After Care Enrollment Application Dear Families, MRA is excited to announce that we will be launching a new lunch program for the 2015/2016 school year. Starng in September, Fresh and Local Meal Program will be providing MRA with a cold lunch program. While we are sll working out the final details, we want to share some informaon with you all. MRA has not offered a full me lunch program since In order to add a lunch program to MRA, it had to meet several criteria. First, it had to align with the mission and vision of MRA. It was important to us that we are offering quality, healthy meals made with the best ingredients. We want our students to have meals that make them feel great and able to do their best learning. Second, we want to be able to offer a free and reduced lunch program for students who qualify. At the boom of this are the income guidelines for the 2015/2016 school year. The free and reduced lunch program will be completely confiden- al - it is crucial to the staff at MRA that there be no differenang between free and purchased lunches. Every lunch will be exactly the same and will be distributed by alphabecal order in the lunch room. Even the staff distribung the lunches will not know who is receiving a free lunch and who is receiving a paid lunch. Purchased student lunches are $3.50 and adult lunches are $4.00. Third, it had to be delicious! Fresh and Local brought out 3 sample lunch meals for our staff to try in the spring. The food was wonderful. We tried the Roast Turkey Sandwich, the Fresh Taco Salad with torlla chips and the Greek Pasta Salad. All were served with organic fruits and vegetables on the side. We had no idea that such great meals could be served in a cold lunch program! Meals opons include things like Mexican Bean and Rice bowl, Chicken Cesar Salad, Quinoa Curry Bowl, Lemon Pepper Chicken Salad Sandwich, Pizza Pasta Salad, and more. In addion, all lunches are peanut free. Vegetarian and gluten free opons are also available. Fresh and Local can even work with our school garden and included our own produce in the lunches we serve. We are confident that not only will the students enjoy these meals, but staff and parents will as well. We will be providing addional informaon in August, including the September menu. And Fresh and Local will be aending parent night on September 3rd. They will be giving out samples and answering quesons about the lunch program. Thank you, Shannon Lishka The free and reduced applicaon forms for 2015/2016 are also available on the ODE website. The link is: hp://

4 Dear MRA Families, Make a Difference! No cost to you fundraising! escrip is fundraising made simple. Want to raise money for Molalla River Academy? Most of us do, we just don t have the time or money to spare. That s where escrip comes in. Free to join, simple to use, nothing to track or sell-you simply fundraise every time you shop and dine out with your registered cards, or when you shop from their Online Mall. Sign up your Safeway Club Card or even your debit/credit card and every purchase helps our students. Just go to and click Sign Up at the top right of the page. If you have signed up in the past but haven't renewed your registered Safeway, Vons or Pavilions grocery card or your debit/credit card, contributions to Molalla River Academy have stopped! However, it's not too late to renew now -- it's quick and easy. There are two ways to renew: Call (800) Visit and Sign In Thank you for taking the time to show your commitment to Molalla River Academy and our community. It is greatly appreciated! Sincerely, MRA Staff

5 Molalla River Academy Dear Parent/Guardian: Children need healthy meals to learn. Molalla River Academy now offers healthy meals every school day. Lunch costs $3.50/student. Your children may qualify for free meals. 1. Do I need to fill out an application for each child? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: Shelley Urben, S. Callahan Rd., Molalla, OR Who can get free meals? Children in households getting Supplemental Nutrition Assistance Program (SNAP) benefits, TANF or FDPIR can get free meals regardless of your income. Also, your children can get free meals if your household income is within the free and reduced limits on the Federal Income Guidelines. 3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or court can get free meals. Any foster child in the household can get free meal regardless of income. 4. Can homeless, runaway and migrant children get free meals? Please call the school office to see if your child(ren) qualifies, if you have not been informed that they will get free meals. 5. If my child is eligible for free or reduced price meal benefits, when will the meal benefits begin? Meal benefits for new applications cannot start until an application is approved. Please provide a lunch or money for a paid lunch until you receive notice that the application is approved. 6. I get WIC. Can my child(ren) get free meals? This can only be determined by completing and submitting the enclosed application for meal benefits. Please fill out an application. 7. My children receive Oregon Health Plan benefits. Can they get free meals? This can only be determined by completing and submitting the enclosed application for meal benefits. Please fill out an application. 8. Will the information I give be checked? Yes, we may ask you to send written proof. 9. If I do not qualify now, may I apply later? Yes. You may apply at any time during the school year. 10. What if I disagree with the school s decision about my application? You should talk to school officials. 11. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals. 12. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself and all children who live with you. Foster children may be included as household members. If you live with other people who are economically independent (for example, people you do not support, who do not share income with you or your children and who pay a pro-rated share of expenses), do not include them. 13. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include it, but not if you get it only sometimes. 14. We are in the military; do we include our housing allowance? If you get an off-base housing allowance, it must be counted as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. 15. My spouse is deployed to a combat zone. Is combat pay counted as income? Combat pay is excluded if it is received in addition to the service member s basic pay; because of the deployment; and not received before being deployed. 16. My family needs more help. Are there other programs we might apply for? To find out how to apply for [State SNAP] or other assistance benefits, contact your local assistance office or Text FOOD to or call ( HUNGRY) or visit If you have other questions or need help, call MRA at Sincerely, Shelley Urben MRA Executive Director Letter to Household Page 1 of 2

6 INSTRUCTIONS FOR APPLYING For Supplemental Nutrition Assistance Program (SNAP) benefits OR Temporary Assistance for Needy Families (TANF) Households, do the following: Part 1: Complete Household information Part 2: List child(ren) s name, school, grade, birthday and mark the checkbox, if they are a formally place foster child in the family. Part 3: Give the name of the person in the household with benefits and their case number, (SNAP) benefits (A ) or TANF (AA111 or AAA111) Part 4: Skip this part. Part 5: Sign the form. A Social Security Number is not necessary. Part 6:.Answer this question if you choose to. Part 7: Answer this question if you choose to. If you are applying for a FOSTER CHILD, follow these instructions: Part 1: Complete Household information Part 2: List child(ren) s name, school, grade, birthday and mark the checkbox, if they are a formally place foster child in the family Part 3: Skip this part Part 4:.Skip this part Part 5: Sign the form. A Social Security Number is not necessary Part 6: Answer this question if you choose to. Part 7: Answer this question if you choose to. OR Complete a household application for the entire household including the foster child following instructions for All Other Households ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions: Part 1: Complete Household information. Part 2: List child(ren) s name, school, grade, birthday and mark if child is foster. Part 3: Skip this part. Part 4: Follow these instructions to report total household income from last month. Column 1 Name: List the first and last name of each person living in your household, related or not (such as grandparents, other relatives, or friends). You must include yourself, those children living with you but not attending school and children in school receiving regular income. Do not repeat children listed in part 2 unless they receive regular income. Attach another sheet of paper if you need to. Column 2 Gross Monthly Income. Next to each person s name, list each type of income received last month. For example, Monthly Income: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. If your income is paid weekly, every 2 weeks or twice a month, follow the instructions on the back of the application. Column 3 - List the amount each person got last month from welfare, child support, alimony. Column 4 List the amount each person got last month from pensions, retirement, Social Security. Column 5 List the amount each person got last month from Worker s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran s benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household, and ANY OTHER INCOME. Report net income for self-owned business, farm, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance. Part 5: An adult household member must sign the form and list the last four (4) numbers of his or her Social Security Number, or mark the box if he or she doesn t have one. Part 6: Answer this question if you choose to. Part 7: Answer this question if you choose to. Letter to Household Page 2 of 2

7 Application # CONFIDENTIAL FAMILY APPLICATION FOR FREE & REDUCED MEALS NOTICE: If you received an ELIGIBILITY NOTIFICATION FREE MEALS from the school district do not complete this application. See Application Instructions on back of form. 1 HOUSEHOLD INFORMATION Print name of person completing this application (Last name, First name) Name Print Mailing Address Apt # City State Zip 2 STUDENT INFORMATION Child s Name (Legal Last name, First name) School Home Phone or Cell Phone or Work (Circle One) address Number living in this household (Write names of all household members on part 2 and/or part 4 of this form) Grade (optional) Birth Date (optional) Check if Foster Child 3 BENEFITS If any member of your household receives SNAP or TANF, provide the name and case number of the member receiving benefits Name Column 1 List all household members, including children not attending school, and income. Do not include students listed in part 2, unless they receive regular income. (Last name, first name) SNAP TANF Case Number Go to Part 5 below Does this household receive FDPIR (Food Distribution on Indian Reservations) Yes (Go Part 5 and complete) 4 HOUSEHOLD MEMBERS & GROSS MONTHLY INCOME if not monthly, see back for conversions Column 2 Column 3 Column 4 Column 5 MONTHLY MONTHLY CHILD MONTHLY OTHER MONTHLY INCOME SUPPORT, PENSIONS, INCOME -Including (Total earnings & WELFARE, SOCIAL unemployment and wages before ALIMONY SECURITY, workers comp. deductions) RECEIVED RETIREMENT Column 6 Check if No Income 5 SIGNATURE, DATE and Last four numbers of SOCIAL SECURITY NUMBER (Adult must sign) I certify (promise) that all of the information on this application is true (correct) and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I give purposely false information, my children may lose meal benefits and I may be prosecuted. Signature of Adult Household Member Date Signed X Month/day/year 6 RACIAL OR ETHNIC GROUP (OPTIONAL) Mark one ethnic identity: Hispanic or Latino Not Hispanic or Latino Mark one or more racial identities: Asian American Indian & Alaskan Native Native Hawaiian or Other Pacific Islander Social Security Number (See privacy statement on back) XXX-XX - Black or African American White, not of Hispanic origin Other I do not have a Social Security Number. I prefer all written correspondence in Spanish Russian Other 7 I do not want my information shared with State children s health insurance programs. Sign here: I have a child (or children) who does not have any kind of health coverage neither private health insurance nor Oregon Health Plan/Healthy Kids. I am interested in free or reduced cost health coverage for at least one of my children. Yes No SCHOOL USE ONLY - DO NOT WRITE BELOW THIS LINE Total Income: Number in household: Date Withdrawn: Free based on: Reduced based on: Denied Reason: SNAP/TANF/FDPIR Foster child categorical household income income too high incomplete application household income Determining Official s Signature : Date Form e-P (Rev. 7/15) Page 1 of 2 SEE IMPORTANT INFORMATION ON REVERSE SIDE

8 Application Instructions If your household receives SNAP, TANF or FDPIR, complete parts 1, 2, 3 and 5; parts 6 and 7 are optional. If you do not receive these benefits and your income is below the guidelines, complete parts 1, 2, 4, 5; parts 6 and 7 are optional. If you are a household with a FOSTER CHILD, complete parts 1, 2, 4, and 5; parts 6 and 7 are optional. Any income fields left blank will be counted as zeros. Please be careful that you meant to leave income fields blank. DETERMINING MONTHLY INCOME FOR EARNINGS & WAGES Monthly income for all household members must be reported in Part 4 of this application. Income means any money regularly received from work, child support, alimony, pensions, retirements, social security or any other source. Exclude student/school loans. 4 Household members who are not paid monthly should change earnings into monthly income by doing the following: Household members who are paid every week: Multiply total earnings and wages for one pay period, before deductions, by 52. Then divide by 12. The resulting amount is the total monthly income. Household members who are paid every 2 weeks: Multiply total earnings and wages for one pay period, before deductions, by 26. Then divide by 12. The resulting amount is the total monthly income. Household members who are paid twice a month: Multiply total earnings and wages for one pay period, before deductions, by 24 then divide by 12. The resulting amount is the total monthly income. Household members who are seasonal workers or work less than 12 months: Project annual rate of income to accurately represent actual circumstances then divide by 12. The resulting amount is the projected monthly income. Note: Money received from a business or farm owned by you should be reported as "net income." Net Income is defined as the total income left after business and farm operating expenses are subtracted from gross receipts. FEDERAL INCOME GUIDELINES Your children may qualify at least for reduced price meals if your household income falls within the limits of this chart. Reduced Price Meals Household Size Annual Monthly Twice Per Every Two Month Weeks Weekly -1-21,775 1, ,471 2,456 1,228 1, ,167 3,098 1,549 1, ,863 3,739 1,870 1, ,559 4,380 2,190 2,022 1, ,255 5,022 2,511 2,318 1, ,951 5,663 2,832 2,614 1, ,647 6,304 3,152 2,910 1,455 For each additional family member add 7, PRIVACY STATEMENT - SOCIAL SECURITY NUMBERS and OTHER INFORMATION The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information but if you do not, we cannot approve your child for free or reduced price meals. You must include the last 4 digits of the social security number of the adult household member who signs the application. The last 4 digits of the social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals and for administration and enforcement of the lunch and breakfast programs. We may share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules. We may share the information on this form with Medicaid or the State Children s Health Insurance Program (SCHIP), unless you tell us not to. The information, if disclosed, will only be used to identify eligible children and seek to enroll them in Medicaid or SCHIP. USDA and this institution are equal opportunity providers and employers. Form e-P (Rev. 07/15) Page 2 of 2 (NSLP)

9 Application # SOLICITUD FAMILIAR CONFIDENCIAL PARA COMIDAS GRATIS Y DE PRECIO REDUCIDO AVISO: Si ha recibido una NOTIFICACIÓN DE ELEGIBILIDAD PARA COMIDAS GRATIS del distrito escolar, no complete esta solicitud. Vea las Instrucciones para completar la solicitud al dorso de este formulario. 1 INFORMACIÓN DEL HOGAR Nombre de la persona que completa esta solicitud (Apellido, Primer nombre) Nombre Escriba Dirección postal Apt # Ciudad Estado Código Postal 2 INFORMACIÓN DE LOS ESTUDIANTES Nombre del niño (Apellido, Primer nombre) Escuela Grado (Opcional) Teléfono particular o móvil (marque uno con un círculo) Teléfono del trabajo Número de integrantes del hogar (Escriba los nombres de todos los integrantes del hogar en las partes 2 y/o 4 de este formulario) Fecha de nacimiento (Opcional) Comprobar si los niños de crianza temporal BENEFICIOS Si algún miembro del hogar recibe SNAP o TANF, dé el nombre y número de caso del miembro que recibe los beneficios. Nombre SNAP TANF Número de caso Recibe este hogar FDPIR (Distribución de comida en reservaciones indígenas) Sí 4 MIEMBROS DEL HOGAR E INGRESO MENSUAL BRUTO si no es mensual, vea las conversiones al dorso Columna 2 Columna 3 Columna 4 Ingreso mensual Manutención infantil, Mensual pensiones, (Ganancias y Asistencia social, Retiro del Seguro sueldos totales Pensión alimenticia Social por mes antes de Recibidas por mes deducciones) Columna 1 Liste todos los miembros del hogar, incluidos niños, que no asisten a la escuela, y el ingreso. No incluya a los estudiantes listados en la parte 2, a menos que reciban ingresos regulares. (Apellido, Primer nombre) Columna 5 Otro Ingreso mensual Incluido Seguro de desempleo Y Compensación laboral Siga abajo en la Parte 5 Columna 6 Marque si no hay ingreso 5 FIRMA, FECHA Y últimos cuatro números del NÚMERO DE SEGURO SOCIAL (Un adulto debe firmar) Certifico (prometo) que toda la información en esta solicitud es verdadera (correcta) y que he informado todos los ingresos. Entiendo que la escuela obtendrá fondos federales en base a la información que proporcione. Entiendo que los funcionarios de la escuela pueden verificar (controlar) la información. Entiendo que si doy información deliberadamente falsa, mis hijos pueden perder los beneficios de comidas y se me puede procesar. Firma de un miembro adulto del hogar Firmado en X Mes/día/año 6 GRUPO RACIAL O ÉTNICO (OPCIONAL) Marque una identidad étnica: Marque una o más identidades raciales: Hispano o latino Asiático No hispano ni latino Indio americano y nativo de Alaska Número de Seguro Social * (Ver declaración de privacidad al dorso) XXX-XX- No tengo número de Seguro Social Negro o afroamericano Blanco, no de origen hispano Otra Nativo de Hawai o de otra isla del Pacífico Prefiero recibir toda la correspondencia en Español Ruso Otro 7 No deseo que mi información se comparta con el programa de seguro de salud de niños del Estado Firme aquí:: Tengo un hijo (o hijos) que no tienen ningún tipo de cobertura de salud ni de seguro de salud privado ni de Oregon Health Plan / Healthy Kids. Estoy interesado en libre o reducción del coste de la cobertura de salud para al menos uno de mis hijos. Sí No SCHOOL USE ONLY - DO NOT WRITE BELOW THIS LINE Total Income: Number in household: Date Withdrawn: Free based on: Reduced based on: Denied Reason: SNAP/TANF/FDPIR Foster child categorical household income income too high incomplete application household income Determining Official s Signature : Date Form e-P - Spanish (Rev. 05/15) Page 1 of 2 VEA INFORMACIÓN IMPORTANTE AL DORSO

10 Instrucciones para completar la solicitud Si su hogar recibe SNAP, TANF o FDPIR, complete las partes 1, 2, 3 y 5; las partes 6 y 7 son opcionales. Si no recibe estos beneficios y su ingreso se encuentra por debajo de las pautas, complete las partes 1, 2, 4 y 5; las partes 6 y 7 son opcionales. Si en su hogar hay un NIÑO BAJO TUTELA TEMPORARIA, complete las partes 1, 2, 4 y 5; las partes 6 y 7 son opcionales. CÓMO DETERMINAR EL INGRESO MENSUAL PARA GANANCIAS Y SUELDOS En la Parte 4 de esta solicitud debe informarse el ingreso mensual de todos los miembros del hogar. El término ingreso significa cualquier dinero que se recibe regularmente por trabajo, manutención infantil, pensión alimenticia, pensiones, retiros, seguro social o cualquier otra fuente. Excluya préstamos estudiantiles/escolares. Los miembros del hogar que no cobran mensualmente deben convertir los ingresos a ingresos mensuales de la siguiente manera: Miembros del hogar que cobran cada semana: Multiplique por 52 los ingresos y sueldos totales de un periodo de pago, antes de las deducciones. Luego divida por 12. La cifra resultante es el ingreso mensual total. Miembros del hogar que cobran cada 2 semanas: Multiplique por 26 los ingresos y sueldos totales de un periodo de pago, antes de las deducciones. Luego divida por 12. La cifra resultante es el ingreso mensual total. Miembros del hogar que son trabajadores de temporada o que trabajan menos de 12 meses: Proyecte el porcentaje de ingreso anual de ingreso para representar correctamente las circunstancias presentes y luego divida por 12. La cifra resultante es el ingreso mensual proyectado. Nota: El dinero que recibe de un negocio o una granja que es de su propiedad se debe informar como ingreso neto. El ingreso neto se define como el ingreso total que queda después de substraer los gastos para operar el negocio o la granja de los recibos brutos. PAUTAS FEDERALES PARA INGRESO Sus hijos pueden calificar al menos para comidas a precio reducido si el ingreso de su hogar cae dentro de los límites de esta tabla. Comidas a precio reducido Tamaño del hogar Anual Mensualmente Dos veces Cada dos por mes semanas Semanalmente -1-21,775 1, ,471 2,456 1,228 1, ,167 3,098 1,549 1, ,863 3,739 1,870 1, ,559 4,380 2,190 2,022 1, ,255 5,022 2,511 2,318 1, ,951 5,663 2,832 2,614 1, ,647 6,304 3,152 2,910 1,455 Para cada miembro adicional de la familia añadir 7, DECLARACIÓN DE PRIVACIDAD NÚMEROS DE SEGURO SOCIAL La ley de almuerzos escolares Richard B. Russell National School Lunch Act ordena que se proporcione la información que se pide en esta solicitud. No tiene que darnos la información, pero si no lo hace, no podemos aprobar las comidas gratuitas o a precios reducidos para su hijo. Usted tiene que incluir los últimos cuatro dígitos del número de Seguro Social del miembro adulto de la unidad familiar que firme la solicitud. Esos últimos cuatro dígitos del número de Seguro Social no se requieren si usted solicita en nombre de un hijo de crianza o si provee un número de caso de los programas Supplemental Nutrition Assistance Program (SNAP), Temporary Asistance for Needy Families (TANF) o Food Distribution Program on Indian Reservations (FDPIR), o bien otro número de identificación del FDPIR para su hijo, y tampoco si indica que el miembro adulto de la unidad familiar que firma la solicitud no tiene un número de Seguro Social. Usaremos su información para decidir si su hijo reúne los requisitos para recibir comidas gratuitas o a precios reducidos, así como para administrar y hacer cumplir los programas de almuerzos y desayunos. PODEMOS compartir su información de elegibilidad con ciertos programas de educación, salud y nutrición para ayudarlos a evaluar, financiar o determinar los beneficios de sus programas, con los auditores de revisión de programas y con funcionarios del orden público para ayudarlos a investigar violaciones de las reglas de los programas. Podemos compartir la información de este formulario con Medicaid o el Programa de Seguro de Salud de Niños del Estado (SCHIP), a menos que usted nos diga que no lo hagamos. La información, si se revela, se utilizará para identificar niños elegibles y tratar de inscribirlos en Medicaid o SCHIP. USDA y esta institución son proveedores y empleadores que ofrecen oportunidad igual a todos. Form e-P- Spanish (Rev. 05/15) Page 2 of 2

11 Molalla River Academy Before and After School Care Program Enrollment Form Please return this form to the school office if you plan on using before or after school care at MRA. One contract per child please. Student Name Grade Birth date Address: City: Zip Code: Phone: Mother s Name: Wk Ph: Cell Ph: Father s Name: Wk Ph: Cell Ph: I have filed the completed the Molalla River Academy Emergency Authorization form and the Emergency Procedure form for the school year with the school. The designated alternates listed on the Emergency Procedure form are authorized to pick up my child from Before or After School Care if I cannot be reached. Authorized to pick up this child: (circle) Mother Father List Any Others Authorized (siblings, relatives, nannies, etc.): Name Phone Name Phone Name Phone Name Phone Food/Life-threatening allergies/medical issues: (Please include any additional information you would like us to know) Hours: Before Care (BC): Monday through Friday 7:00 a.m. to 7:50 a.m. After Care (AC): Monday, Tuesday, Thursday and Friday 3:05 p.m. to 6:00 p.m. Wednesday 1:05 p.m. to 6:00 p.m. Hourly Rate: $5.00 per child assessed by the quarter hour ( ) My child will attend Before School Care every day, Monday through Friday, unless I notify the office otherwise. ( ) My child will attend After School Care every day, Monday through Friday, unless I notify the Office otherwise. ( ) My child will always attend the circled days and times (BC = Before Care, AC = Aftercare), unless I notify the office otherwise: Monday ( BC / AC ) Tuesday ( BC / AC ) Wednesday ( BC / AC ) Thursday ( BC / AC ) Friday ( BC / AC ) ( ) My child will attend occasionally. I will call and notify the office before 7:00 a.m. for before care and before my child s class lets out for after care. All before and after school care will be billed on my MRA monthly statement. Delinquent accounts going unpaid for over 30 days without payment will result in suspension of aftercare attendance until such time as payment is made. Returned checks will be charged a twenty-five dollar ($25.00) fee. To assure the safety of the children we must know who to expect each day. When you deviate from your schedule please call the school or leave a voice mail at or at jpapineau@mra-k8.com. Parent Signature Date Parent Signature Date

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