Request for Information
REQUEST FOR INFORMATION
(Complete one form per family)
Please answer the question below by checking the appropriate box. The following information is a request adopted by the General Assembly in 2010 requiring school districts to determine whether or not all children in a family have health insurance.
Does each child in your family have healthcare insurance?
MO HealthNet (Medicaid) is considered healthcare insurance.
If NO is checked the school district will provide the Does Your Child Need Healthcare Coverage form for the family.
Completion of this form is not a condition of determining meal eligibility. The Free and Reduced Price Meals Family Application will be reviewed regardless of your response to this Request for Information.
Submit this request with your Free and Reduced Price School Meals Family Application or return to your school/school district.
Printed name of parent/guardian: __________________________________________________________________
Mailing Address: ________________________________________________________________________________
City: _______________________________________________State: ____________________ Zip Code: _________
The Department of Elementary and Secondary Education does not discriminate on the basis of race, color, religion, gender, national origin, age, or disability in its programs and activities. Inquiries related to Department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may be directed to the Jefferson State Office Building, Office of the General
Counsel, Coordinator – Civil Rights Compliance (Title VI/Title IX/504/ADA/Age Act), 6th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 65102-0480; telephone number 573-526-4757 or TTY 800-735-2966; email email@example.com.