dundycountystrattonpublicschools

DUNDY COUNTY STRATTON PUBLIC SCHOOLS
400 9th Avenue West • P.O. Box 586 • Benkelman, NE 69021-0586
“Every Day…Every Child…A Success!”
July 22, 2013
Dear Parent or Guardian:
Welcome Back! The summer break from school is winding down and school begins soon. While
we hope your summer has been a good one, we are ready to welcome you back for the 2013-2014
school year. Classes begin on August 14.
We are looking forward to the upcoming year, we have a great team of Students, Patrons,
Teaching Staff, Support Staff, Principals and members of the Board of Education who are
committed to continuing to develop and improve an already high quality educational program at
Dundy County Stratton Public Schools.
There are always many questions to be answered concerning a new school year, the following
information is intended to help answer some of those questions. If you need any other information
please feel free to contact Mr. Phil Truax, Secondary Principal/Activities Director; Mr. Michael
Rotherham, Benkelman/Stratton Elementary Principal or myself. Mr. Rotherham will be in both
elementary buildings on a weekly basis. We also have a toll free number into the high school; it is
866-463-2738.
We will start at 8:00 a.m. MT at the high school, 8:20 a.m. CT at Stratton Elementary, 8:00 a.m.
MT and at Benkelman Elementary with an early dismissal. Buses will run accordingly. Lunch will
be served at Benkelman and Stratton.
Accreditation – We are fully accredited by the North Central Association of Colleges and Schools,
and the Nebraska Department of Education.
Demographics – We serve the needs of approximately 380 students in the rural areas of Dundy
County and western Hitchcock County and the communities of Benkelman, Haigler, Max, Parks
and Stratton. The district comprises approximately 1050 square miles. Attendance centers are
Benkelman Elementary (K-6), Stratton Elementary (K-6) and Dundy County Stratton High School
(7-12). We also contract with Educational Service Unit 15 for special needs on an as needed basis.
Special Education Services – As per Nebraska law, DCS provides services to qualified special
needs district residents. If you need information concerning special education services, please
contact our district office.
Communication – During the year the “State of the Schools Report will be published in The
BENKELMAN POST and HITCHCOCK COUNTY NEWS and on the school’s website
(www.dcstigers.org) each month. Legal notices/minutes of the Board of Education will be printed
in the BENKELMAN POST (monthly). An ad concerning the start of school will appear in the
BENKELMAN POST and HITCHCOCK COUNTY NEWS on July 31 of this year. The high school
sends out daily announcements that contain schedules, lunch for the day, meetings, college visits,
etc. If you would like these announcements emailed to you please contact Sonya at the high
school or email your address to [email protected]. We will also continue the use of the Code
Red notification system. This system will allow you to receive notifications of school-related
closings, postponements and announcements via cell phone, text message, home phone or email. If you would like to sign up to receive such notices please contact Sonya at the high school
([email protected]).
Mr. Mike Rotherham • Elementary Principal
Mr. Jim Kent
Mr. Phil Truax
Superintendent
308.423.2738
Fax: 308.423.2711
HS Principal • Activities Director
308.423.2738
Fax: 308.423.2711
EQUAL OPPORTUNITY EMPLOYER
Benkelman Elementary
308.423.2216
Fax: 308.423.2320
NORTH CENTRAL ACCREDITED
Stratton Elementary
308.276.2281
Fax: 308.276.2129
NEBRASKA ACCREDITED
Weather Related School Closing – Announcements for the closing of school for weather related reasons will
be announced via the following media: KIOD Radio, NTV Television, Code Red, Benkelman and Haigler cable
television, and electronically at www.weatherthreat.com or http://www.bwtelcom.net (click on BW Channel 37).
Generally, early dismissals will be announced by noon and closings or late starts will be released around 6:00
a.m. MT, 7:00 a.m. CT.
Student Fees – The District’s policy is to provide for free instruction in accordance with the Nebraska State
Constitution. The District also provides activities, programs, and services that extend beyond the minimum level
of constitutionally required free instruction. Under the Public Elementary and Secondary Fee Authorization Act,
the District is permitted to charge students fees for these activities or to require students to provide specialized
equipment and attire for certain purposes. Students are encouraged to contact the Activities Director for further
information.
School Time/Athletic Supplemental Insurance – A supplemental insurance program is available at the
Elementary and Junior/Senior High. All students will be receiving a brochure of information about schooltime
insurance during the first week of school. The district does not provide any form of student insurance.
Medication-No medication, including aspirin, is dispensed to any student unless the appropriate paperwork is
filled out. A release must be filled out by the parent for over-the-counter medication and by the family physician
for prescription medication. The school does not provide such medication; parents should bring it to the school
in the original container. If your student requires medication, please pick up the proper forms in the building
office.
School Physicals—State Law requires any student entering kindergarten, 7th grade, anyone participating in
athletics, and anyone entering from out of state to have a physical. Forms are available at the high school.
Transportation – Dundy County Stratton Schools provides daily transportation for all students who qualify. A
bus driver will be contacting patrons prior to the start of school to set up times for each stop. Robert Castillo is
the supervisor/mechanic for the transportation department of Dundy County Stratton Public Schools. If you
have questions about transportation contact the Superintendent, Principals or Robert at 423-2305.
New Students - If you are new to the district please contact the school as soon as possible to register your
children and to arrange for transportation services if required.
Pre-School – The district offers a pre-school at Benkelman Elementary. If you have questions or wish to sign a
child up, contact Mr. Rotherham at Benkelman Elementary.
Sincerely,
Jim Kent, Superintendent
Dundy County Stratton Public Schools
Contents of Mailing
A.
High School Principal comments
B.
Elementary Principal comments
C.
Supply lists for Benkelman and Stratton Elementary Schools
D.
2013-14 School Calendar
E.
Parent Agreement Computer/Internet Use
F.
Laptop Checkout Form (9th-12th Grades Only)
These forms should be completed and returned
G.
School Lunch Information
A. High School Principal’s Comments
Dear students, parents and guardians of Dundy County Stratton High School:
Welcome back to school. Hopefully your summer went well and you were able to find a bit of time for some
rest and relaxation. The staff here at DCS High School is ready to get back to work serving the students of our
district. We are very proud of the educational programs we offer our area’s young people, and I can assure
you we will do our best to fulfill our motto, working “Every Day” to help “Every Child” achieve “Success”. This
year, we will put a renewed emphasis on the respectful and positive attitude we treat each other with in and
outside of school. The theme this year is “None of us is as strong as ALL of us!” With that phrase in mind, we
will take special account of treating each other with respect at all times. As administrators, teachers, staff,
students, and stakeholders, we will strive to be dependable, prepared, respectful, and full of pride for our
school community every day. This will be our framework for individual and school success.
There will be some changes in the everyday schedule this year at the high school. In addition to offering some
new classes (History in the Media, Outdoor Biology, etc.), we have adjusted the time frame of our schedule to
create a little more time during passing periods to allow students a more realistic opportunity to get to every
class on time and prepared. We have also instituted a “homeroom” class that will meet every morning. This
class will have a very important purpose, and will allow our students and teachers time to work on homework
and receive or give help on questions that may have come up on assignments. Another change to this year’s
schedule will be the loss of teacher’s aide and work study opportunities. On the other hand, we have added a
senior release period at the end of the day, for those seniors who qualify and would like to take advantage of
the extra hour for work opportunities. Another important change this year involves our 7th grade students.
They will start their day at the high school this year, and will take all of their core classes here. The 7 th/8th
graders will still travel to the elementary for lunch, sports, and certain “CASH” classes, but we’re excited to
include the 7th grade students for a bigger portion of the day.
We will continue to use Infinite Campus this year. This program is capable of tracking grades, attendance,
lunch count and other things. A parent log-in will also be available to allow parents to access their students’
information. The program may be accessed via the following web address:
https://nemstcloud.infinitecampus.org/campus/dundy.jsp or via the school web page at www.dcstigers.org. If
you had a Login ID and password last year, they will be the same. If you do not have one contact Stacey
Waters at the high school office and she will set you up.([email protected]).
Students in grades 9-12 can now check their schedules for this fall on their Infinite Campus user account. If
there are openings in schedules or if changes need to be made, Mrs. Matthews will be available at the High
School on Monday August 5th through Friday August 9th from 8:00 - 12:00 and 1:00 – 3:00. Junior High
students may pick up their schedules at the same times and days, at the HIGH SCHOOL. Locker
assignments may also be picked up during this time. If Infinite Campus passwords have been forgotten,
please call Stacey at the high school (423-2738) for assistance.
IMPORTANT DATES TO REMEMBER
August
5-9
12
12,13
14
19
Registration, JH Schedule pickup 8:00-12:00 and 1:00 – 3:00
Start of fall practice-- football and girls’ golf
Teacher workdays
First full day of classes (early dismissal)
Start of fall practice -- volleyball and cross country
Again, welcome back to school. I look forward to seeing you on the 14th of August.
Go Tigers!
Phil Truax, High School Principal
B.
ELEMENTARY PRINCIPAL’S COMMENTS
Dear Parents and Students,
On the first day of school, August 14th classes will begin at 8:20 a.m. CT at Stratton Elementary,
and 8:00 a.m. MT for kindergarten through 6th grade at Benkelman Elementary. Regular
schedule Monday thru Thursday will be 8:20 a.m. CT to 3:35 p.m. CT at Stratton and 8:00 a.m.
MT to 3:30 p.m. MT at Benkelman Elementary. Fridays we will run an early release schedule.
School will dismiss at 1:35 p.m. CT at Stratton Elementary and 1:46 p.m. MT for Benkelman
Elementary.
Wednesday, August 14 will be an early dismissal.
Just a reminder to start getting your child ready for their “school schedule”. Please have your
child start spending some time on reading and writing skills as well as getting them back on a
regular bedtime schedule.
We have three new teachers at Benkelman Elementary for this school-year. Amanda Benson
will be teaching 2nd grade, Kacie Ruppert will be teaching 4th grade, and Allie Kenning will be the
new 5th grade teacher. Two teachers will have new assignments. Cindy McVicker will take over
Title I teaching duties and Kathy Blecha will teach math and reading to grades 4-6.
As always anytime during the year if you have concerns please feel free to contact me.
Working together we can continue to make Dundy County Stratton School a great place for our
kids.
Thanks for all your support,
Mike Rotherham
Elementary Principal
C.
Supply lists for Benkelman
Kindergarten
Mrs. Freeland, teacher
Consumables
4 boxes of small crayons
2 - lg pencils
1 - dz #2 pencils
2 - boxes Kleenex
1 - lg eraser
6-10 glue sticks
2nd Grade
Mrs. Benson, teacher
Consumables
1 - box of crayons
1 - lg eraser
2 - lg glue sticks
Kleenex
1 dz #2 pencils
1 - 3 ring binder ( 1" or larger)
2 - black dry erase markers
4th Grade
Mrs. Ruppert, teacher
Consumables
wide lined paper
#2 pencils
1 - lg eraser
glue stick
Kleenex
Disretionary
1 - plastic school box
1 - small plastic drinking cup w/lid
(empty water bottles work great)
1 - book bag
1 - two pocket folder
1 - coloring book
Discretionary
1 - book bag
1 - pr sharp point scissors
1 - pocket folder (bottom pockets)
1 - sm plastic school box
Discretionary
crayons (16-24)
colored pencils
1 - pocket folder (for loose papers)
2-wide lined spiral notebook
6th Grade
Mrs. Stamm, teacher
Consumables
colored pencils
2 - red pens
pens (black or blue)
paper (college ruled)
glue or glue stick
Kleenex
pencils
Discretionary
scissors
ruler (inch/centimeter markings)
protractor
6 pocket folders or Trapper
Keeper with folders
Jumbo book covers
1st Grade
Mrs. Burrell, teacher
Consumables
1 dz #2 pencils
2 - lg eraser
4 - lg glue sticks
Kleenex
4 -boxes of crayons (8 or 16)
hand sanitizer*
3rd Grade
Mrs. Hudson, teacher
Consumables
wide lined paper
#2 pencils
1 - lg eraser
glue stick
Kleenex
5th Grade
Miss Kenning, teacher
Consumables
#2 pencils
notebook paper
colored pencils
glue
2 - red pens
erasers
Kleenex
7th & 8th Grades
Consumables
ink pens (black or blue no
flourescent ones)
eraser
1 - 1 1/2" three ring binder
Kleenex
#2 pencils (at least #2)
notebook paper (loose leaf)
Discretionary
1 - pr sharp point scissors
1 - sm pencil box
1 - sm pillow
1 - book bag
1 - sm plastic bottle w/lid
Discretionary
markers
scissors
ruler (inch/centimeter markings)
2 - pocket folder
(for loose papers)
Discretionary
scissors
colored pencils, markers
ruler (inch/centimeter markings)
6 - pocket folders or Trapper
Keeper with folder
Discretionary
ruler (inch/centimeter markings)
protractor & compass
Trapper Keeper (or closing
notebook w/folders)
gym/book bag (must fit in locker)
colored pencils (8ct)
tab/subject dividers (1 set of five)
If your child has these supplies from last year most teachers will accept them this year as well.
*Hand sanitizer is optional, if you would like to donate a large bottle for your class it would be most appreciated.
PLEASE MARK ALL ITEMS WITH YOUR CHILD'S NAME, THIS INCLUDES BOOK BAGS, COATS, LUNCH BOXES, etc.
7/11/2013
STRATTON ELEMENTARY
KINDERGARTEN
1ST & 2ND
3RD & 4TH
5TH & 6TH
SCISSORS
1 POCKET FOLDER
3 BOXES KLEENEX
RULER
-Fiskars metal round tip
CRAYONS (24CNT)
PENCILS
ACCORDIAN FOLDER
CRAYONS
1 BOTTLE OF GLUE
RED PEN
2 POCKET FOLDERS
-1 pk 24, 1 pk 8
#2 PENCILS (12)
BLACK/BLUE PEN
2 SPIRAL NOTEBOOKS
2 BOTTLES GLUE
1 RUBBER ERASER
PENCIL TOP ERASERS
1 PACK OF MARKERS
PENCILS
PENCIL BOX
2 DRY ERASE MARKERS
SCISSORS
-no glitter or plastic
PAINT SHIRT
1 PACK OF MARKERS
2 GLUE STICKS
2 POCKET FOLDERS
BOOK BAG
PENCIL BOX
2 BOXES KLEENEX
-pockets on BOTTOM
SCISSORS
SCISSORS
PENCILS
PENCIL BOX
PE SHOES
2 SPIRAL NOTEBOOKS
RED PEN
-cigar box size no larger
PLASTIC RULER
1 POCKET FOLDER
BLACK/BLUE PEN
BOOK BAG
3 BOXES KLEENEX
PE SHOES
PE BAG W/ ATTIRE
-must fit large book
1 SPIRAL NOTEBOOK
PAINT SHIRT
-must cover clothes
PE SHOES
1 BOX KLEENEX
PILLOW OR MAT FOR REST TIME
**PLEASE LABEL ALL ITEMS BEFORE THEY COME TO SCHOOL**
Dundy County Stratton Schools Calendar
2013-2014
August
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January
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8 9 10
15 16 17
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29 30 31
4 5 6 7
11 12 13 14
18 19 20 21
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13 Workday
6
Classes resume
14 Students
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12 13 14
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26 27 28
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September
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8 9 10 11 12 13 14
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29 30
2 Labor Day
14 Workday
27 Inservice
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October
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8 9 10 11 12
15 16 17 18 19
22 23 24 25 26
29 30 31
6 7
13 14
20 21
27 28
24 PTC 2-8 (early dismissal)
13 Spring Break
14 Spring Break
20 PTC 4-8 (regular dismissal)
25 Fall Break
November
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8 In-service
18 Good Friday
21 Easter Monday
28 Thanksgiving
29 Thanksgiving
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30 31
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20 21
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May
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29 30 31
20 End of Semester
21 Last Day
22 Workday
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ACCEPTABLE USE OF COMPUTERS AND THE NETWORK
PARENT’S AGREEMENT
As a parent/guardian please sign the following statement:
I have received a copy of, and have read, the “Terms and Conditions for Computer Equipment,
Network, E-mail and Internet access” adopted by this school district. As parent or guardian of
the student named below, I grant permission for my son or daughter to have access to the
network, including electronic mail (e-mail) and the Internet. I understand that this free access is
designed for educational purposes. I also understand and agree that individuals and users may be
held liable or disciplined for violations of the Terms and Conditions. Students will be liable for
any financial obligations that arise because of a violation of guidelines. I also understand and
agree that privacy interests and confidentiality are hereby being relinquished and waived, and
that it is impossible to restrict access to all controversial materials, and will not hold this school
district responsible for same. I understand and agree not to hold this school district or any of its
employees, agents, institutions, or networks providing access to networks responsible for the
performance of the system or the content of any material accessed through it.
Student’s Name _____________________________________________________________
Student’s Grade _________________
Date ______________________
Parent/Guardian Signature ____________________________________________________
STUDENT’S AGREEMENT
As a student user please sign the following statement:
I have received a copy of, and have read, the “Terms and Conditions for Computer Equipment,
Network, E-mail and Internet access” adopted by this school district, and I understand and will
abide by those terms and conditions for access and the use of same. I understand that this free
access is designed for educational purposes. I further understand and agree that individuals and
users may be liable or disciplined for violation of those terms and conditions, or that the same
may constitute a criminal offense. I also understand and agree that privacy interests and
confidentiality are hereby being relinquished and waived and will not hold this school district
responsible for same. I agree not to hold this school district or any of its employees, agents,
institutions, or networks providing access to networks responsible for the performance of the
system or the content of any material accessed through it.
Student’s Signature ________________________________
Date ____________________
F.
Dundy County Stratton High School
Parent Permission Form
For Computer/Equipment Checkout (Grades 9-12)
The student and parent(s) listed below accept responsibility for the return of the received items to Dundy CountyStratton Schools. Should the checked items be damaged, fail to operate upon return, or be lost or stolen, the
student and parent(s) listed below accept responsibility and agree to provide identical replacement or repair within
a 30-day period of time.
Signature by the parent(s) confirm that they either have homeowners insurance that will cover such loss or
damage as listed above, or accept the possibility of a cash payment to Dundy County-Stratton Schools for loss or
damage.
Signature by the student or parent(s) further indicates that they fully agree that no copy of the software will be
made, transferred or otherwise duplicated in accordance with federal copyright laws.
Student/parent(s) also agree to return the computer to the Principal or Technology Coordinator by 8:00 a.m. the
next school day. If the student will not be in school due to health or any other reason, it is the student/parent(s)
responsibility to notify the school of the absence and to return the computer on the next school day. Computers
are reserved by others and MUST be returned on time for classroom usage. Failure to return computers on the
date and time that they are due back may cause the student to lose computer checkout privileges for the remainder
of the school year. (Lateness due to weather, bus breakdowns or other incidents beyond the student's control will
not be counted against the student. Student must see the Principal or Technology Coordinator under these
circumstances.)
Reservations must be made no later than lunchtime of the day the student wishes to take the computer home by
filling out a reservation form from the Principal or Technology Coordinator. Once the student has reserved the
computer, it is the student's responsibility to pick up the computer or notify the Principal or Technology
Coordinator if they wish to cancel the reservation prior to 7th period of the day they wish to take the computer
home. Failure to do so will result in a loss of checkout privileges for a period of 30 days from the reservation date.
Today's Date _______________________________
Student's Signature _______________________________________________________________
Student's Name (PRINTED) ________________________________________________________
Parent's Signature ________________________________________________________________
Parent's Name (PRINTED) _________________________________________________________
Home Phone # ________________________ Parent's Work # ________________________
Time and place that parent prefers to be called (between 7:30 a.m. - 3:00 p.m.) ________________
G. SCHOOL LUNCH PROGRAM
The Dundy County Stratton Public School Lunch Program meets or exceeds the requirements of the
state and national school lunch guidelines on nutrition and other requirements. We have kitchens
in Benkelman, Stratton and Haigler that serve meals daily. Visitors are welcome to eat with us,
but should notify the school in advance. Students may purchase means on a daily, weekly or
monthly basis. The prices for meals are:
Adult
Student K-6
Student 7-12
Reduced K-12
Extra Milk/Juice
Breakfast Daily
$3.05
$2.45
$2.45
$0.30
$0.35
Lunch Daily
$4.05
$2.80
$3.05
$0.40
$0.35
When purchasing meals, please make checks payable to: DUNDY COUNTY STRATTON SCHOOL
LUNCH.
Application forms for free and reduced meals follow in this mailing. If you qualify please
complete the enclosed forms and return them to the school your child attends. You must answer all
questions on the forms. This program is funded by the state and federal government and
completion for this application must be followed according to their guidelines.
Attachment B: 2013-14
Dundy County Stratton Public Schools
July 17, 2013
Dear Parent/Guardian:
Children need healthy meals to learn. Dundy County Stratton Public Schools offers healthy meals
every school day. Breakfast costs $2.45; lunch costs K-6 $2.80, 7-12 $3.05. Your children may
qualify for free meals or for reduced-price meals. Reduced-price is $ .30 for breakfast and $ .40 for
lunch.
If your child(ren) qualified for free or reduced-price meals at the end of last school year, you must
submit a new application September 1, 2013 in order to avoid an interruption in meal benefits.
Frequently asked questions and answers:
1. Do I need to fill out an application for each child?
No. Complete the application to apply for free or reduced-price meals. 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: Dundy County Stratton Public Schools, Attn: JoAnn Decker, P.O.
Box 586, Benkelman NE 69021-0586.
2. Who can get free meals?
All children in households receiving benefits from the Supplemental Nutrition Assistance Program
(SNAP), Food Distribution Program on Indian Reservations (FDPIR) or Temporary Assistance to
Needy Families (TANF) can get free meals regardless of your income. Also, your children can get
free meals if your household’s gross income is within the free limits on the Federal Income
Eligibility Guidelines.
3. Can foster children get free meals?
Yes, foster children that are under the legal responsibility of a foster care agency or court are
eligible for free meals. Any foster child in the household is eligible for free meals regardless of
income.
4. Can homeless, runaway and migrant children get free meals?
Yes, children who meet the definition of homeless, runaway or migrant qualify for free meals. If
you haven’t been told your children will get free meals, please call Dundy County Stratton
Public Schools to see if they qualify.
5. Who can get reduced price meals?
Your children can get low cost meals if your household income is within the reduced price limits on
the Federal Eligibility Income Chart shown with this application.
6. Should I fill out an application if I received a letter this school year saying my children are
approved for free meals?
Please read the letter carefully and follow the instructions. Call the school at 308-423-2738 or 866-463-2738
if you have questions.
7. My child’s application was approved last year for meal benefits. Do I need to fill out another one?
Yes, your child’s application is only good for that school year and for the first few days of this school year. You
must send in a new application unless the school told you that your child is eligible for the new school year.
8. I receive WIC. Can my child(ren) get free meals?
Nebraska Department of Education – Nutrition Services
National School Lunch Program
Page 1 of 4
Attachment B: 2013-14
Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an
application.
9. Will the information I give be checked?
Yes, we may ask you to send written proof.
10. If I don’t qualify now, may I apply later?
Yes, you may apply at any time during the school year. For example, children with a parent or
guardian who becomes unemployed may become eligible for free or reduced price meals if the
household income drops below the income limit.
11. What if I disagree with the school’s decision about my application?
You should talk to school officials. You also may ask for a hearing by calling or writing to: Jim
Kent, Superintendent, P.O. Box 586, Benkelman NE 69021, phone number 308-423-2738 or
866-463-2738.
12. 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 U.S. citizens to qualify for free or reduced price
meals.
13. 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) who share income and expenses. You must include yourself and all children
living with you. If you live with other people who are economically independent (for example,
people who 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.
14. What if my income is not always the same?
List the amount that you normally receive. For example, if you normally make $1000 each month,
but you missed some work last month and only made $900, put down that you make $1000 per
month. If you normally get overtime, include it, but do not include it if you only work overtime
sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
15. We are in the military. Do we include our housing allowance as income?
If you get an off-base housing allowance, it must be included as income. However, if your housing
is part of the Military Housing Privatization Initiative, do not include your housing allowance as
income.
16. My spouse is deployed to a combat zone. Is his combat pay counted as income?
No, if the combat pay is received in addition to his basic pay because of his deployment and it
wasn’t received before he was deployed, combat pay is not included as income. Contact your
school for more information.
17. My family needs more help. Are there other programs we might apply for?
To find out how to apply for SNAP or other economic assistance benefits, please go online to
ACCESSNebraska.ne.gov or call 1-800-383-4278.
If you have other questions or need help, call JoAnn Decker at 308-423-2738 or 866-463-2738.
Si necesita ayuda, por favor llame al teléfono: Edna Rotherham at 308-423-2216.
Si vous voudriez d’aide, contactez nous au numero: Edna Rotherham at 308-423-2216.
Sincerely,
Dundy County Stratton Public Schools
Nebraska Department of Education – Nutrition Services
National School Lunch Program
Page 2 of 4
Attachment B: 2013-14
Instructions for Completing the Free & Reduced Priced School Meals Family
Application
If your household receives benefits from the Supplemental Nutrition Assistance Program (SNAP),
Temporary Assistance to Needy Families (TANF) or the Food Distribution Program on Indian
Reservations (FDPIR), follow these instructions:
Part 1:
Part 2:
Part 3:
Part 4:
Part 5:
List each child’s name, the school they attend and their grade.
Enter household’s Master Case Number if the household qualifies for SNAP, TANF or FDPIR.
Skip this part.
Sign the form. The last four digits of a Social Security Number do not need to be reported.
Answer this question if you choose to.
If you are applying for a FOSTER CHILD, follow these instructions:
If all children in the household are foster children:
Part 1: List all foster children, the school they attend and their grade. Check the box indicating the child is a
foster child.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Sign the form. The last four digits of a Social Security Number do not need to be reported.
Part 5: Answer this question if you choose to.
If some of the children in the household are foster children:
Part 1: List all children, including foster children, the school they attend and their grade. Check the box if the
child is a foster child.
Part 2: If the household does not have a Master Case Number, skip this part.
Part 3: Follow these instructions to report total household income from last month.
Column 1 – Household Names: List the first and last name of each person living in your household,
related or not (such as grandparents, other relatives or friends) who share income and expenses.
Attach another sheet of paper if necessary.
Column 2 - Gross Income and How Often it was Received: For each household member, list each
type of income received for the month. You must also report how often the money is received –
weekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income,
not the take-home pay. Gross income is the amount earned before taxes and other deductions.
You should be able to find it on your pay stub or your boss can tell you. For other income, list the
amount each person received for the month from welfare, child support, alimony, pensions, retirement,
Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits) and disability
benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits,
regular contributions from people who do not live in your household and any other income. For
individuals who are self-employed, report income after expenses from business, farm or rental
property. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster
payments received by the family from the placing agency. If you are in the Military Privatization
Housing Initiative or receive combat pay, do not include these allowances as income.
Column 3–Check if NO income: If the person does not have any income, check this box.
Part 4: An adult household member must sign the form and list the last four digits of their Social Security
Number OR mark the box if he/she doesn’t have one.
Part 5: Answer this question if you choose to.
Nebraska Department of Education – Nutrition Services
National School Lunch Program
Page 3 of 4
Attachment B: 2013-14
For ALL OTHER HOUSEHOLDS, including WIC households, follow these instructions:
Part 1: List all children, including foster children, the school they attend and their grade. Check the box if the
child is a foster child.
Part 2: If the household does not have a Master Case Number, skip this part.
Part 3: Follow these instructions to report total household income from last month.
Column 1 – Household Names: List the first and last name of each person living in your household,
related or not (such as grandparents, other relatives or friends) who share income and expenses.
Attach another sheet of paper if necessary.
Column 2 - Gross Income and How Often it was Received: For each household member, list each
type of income received for the month. You must also report how often the money is received –
weekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income,
not the take-home pay. Gross income is the amount earned before taxes and other deductions.
You should be able to find it on your pay stub or your boss can tell you. For other income, list the
amount each person received for the month from welfare, child support, alimony, pensions, retirement,
Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits) and disability
benefits. Under All Other Income, list Worker’s Compensation, unemployment or strike benefits,
regular contributions from people who do not live in your household and any other income. For
individuals who are self-employed, report income after expenses from business, farm or rental
property. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster
payments received by the family from the placing agency. If you are in the Military Privatization
Housing Initiative or receive combat pay, do not include these allowances as income.
Column 3–Check if NO income: If the person does not have any income, check this box.
Part 4: An adult household member must sign the form and list the last four digits of their Social Security
Number OR mark the box if he/she doesn’t have one.
Part 5: Answer this question if you choose to.
Nebraska Department of Education – Nutrition Services
National School Lunch Program
Page 4 of 4
Attachment E: 2013-14
Computing Income for Self-Employed Individuals
Individuals who are self-employed or engaged in farming may experience variations in cash flow
and cannot easily report a monthly income. These individuals may use their 2012 U.S. Individual
Income Tax Return Form 1040 to report self-employment income for the free and reduced price
meal application. The income to be recorded is income derived from the business venture less
operating costs incurred in the generation of that income. Deductions for personal expenses, such
as interest on home mortgages, medical expenses and other similar non-business items are not
allowed in reducing gross business income.
USDA has announced that losses (negative numbers) on the lines listed below can be used to
determine the total income for this attachment. If the total income is a negative number, it must
then be recorded as zero on the application in the category labeled “All Other Income”.
Zero income resulting from the use of Form 1040 does not require follow-up.
Please note: Line 7 cannot be reported as current income. Income from wages or salaries must
be reported on the application for the most recent month.
Line 22 (total income) and line 37 (adjusted gross income) may not be used for purposes of
applying for free and reduced-price meals.
The required information for determining the allowable income from self-employment is to be
taken from the 2012 U.S. Individual Income Tax Return Form 1040.
NOTE: If any members of the
household have income from
wages or salary, the gross income
from last month must be reported
on the application form.
Line 12, Business Income (or loss)
Line 13, Capital Gain (or loss)
Line 14, Other Gains (or losses)
This attachment is used only to
report income from selfemployment and/or farming.
Line 17, Rental Real Estate, etc.
Line 18, Farm Income (or loss)
Total of above lines:
(or loss)
equals annual self-employed income*
If the total of the above lines is a negative number, it must be changed to zero before it is
transferred to the application.
* This figure is to be reported on the application under “All Other Income”.
NE Department of Education – Nutrition Services
National School Lunch Program
Page 1 of 1
Attachment L: 2013-14
Sharing Information with Other Programs - Optional
Dear Parent/Guardian:
To save you time and effort, the information you gave on your Free and Reduced-Price School
Meals Application may be shared with other programs for which your children may qualify.
For the following programs, we must have your permission to share your information.
Sending in this form will not change whether your children get free or reduced price meals.


Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with Title I.
Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with Special Educations.
If you checked “yes” to any or all of the boxes above, complete the following form to ensure
that your information is shared for the child(ren) listed below. Your information will be shared
only with the programs you checked.
Child’s Name:
School:
Child’s Name:
School:
Child’s Name:
School:
Child’s Name:
School:
Signature of Parent/Guardian:
Date:
Printed Name:
Address:
For more information, you may call JoAnn Decker at 308-423-2738 or 866-463-2738 or email at
[email protected].
Return this form to: Dundy County Stratton Schools by August 21st, 2013.
NE Department of Education – Nutrition Services
National School Lunch Program
Page 1 of 1
Free & Reduced Price School Meals Family Application – complete one application per household
Attachment C: 2013-14
Part 1: Children in School
List names of all children, including foster children, in school.
If all children listed are foster, skip to Part 4 to sign the form.
(First, Middle Initial, Last Name)
Check box
below if a
foster child.
Name of School Child Attends
Grade





Part 2: SNAP, TANF or FDPIR Benefits
Enter MASTER CASE NUMBER if household qualifies for SNAP, TANF or FDPIR:
(Social Security numbers, Medicaid numbers and EBT numbers are not accepted.) Skip to Part 4
Part 3: Total Household Gross Income - You must tell us how much and how often.
1. Household Names
2. Gross Income and How Often it was Received
3.
List everyone in household and the
Check
Pensions, Retirement,
income each earns & how often OR
if NO
Earnings from Work Welfare, Child
Social Security, SSI, All Other Income
check the box at the right if they have before deductions
income
Support, Alimony
VA Benefits, Disability (Self Employment)
no income. A foster child’s personal
Income How often Income How often Income How often Income How often
use income must be listed.









Part 4: Signature and Social Security Number (Adult Must Sign)
An adult household member must sign the application. If Part 3 is completed, the adult signing the form must list the last four digits of their
Social Security Number or mark the “I do not have a Social Security Number” box. (See Use of Information Statement on page 2)
I certify (promise) that all information on this application is true 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 purposely
give false information, my children may lose meal benefits and I may be prosecuted.
Sign here: ____________________________________Print name:______________________________________Date:__________
Address:___________________________________________________Zip___________ Phone Number:______________________
Social Security Number (last 4 digits): XXX – XX – __ __ __ __
 I do not have a Social Security Number
Part 5: Children’s Ethnic and Racial Identities (Optional)
Mark one Ethnic Identity: - - and - - Mark one or more Racial Identities:
 Hispanic or Latino
 Asian
 Black or African American
 Not Hispanic or Latino
 White
 American Indian or Alaska Native
Do Not Fill Out This Part. For School Use Only.
 Native Hawaiian or
other Pacific Islander
Annual Income Conversion: Weekly X 52; Every 2 Weeks X 26; Twice a Month X 24; Monthly X 12
Total Household Size_________
Free

Total Income $ ______________ per
 Year  Month  2 X Mo.  Every 2 Wks  Week
Categorically Eligible: SNAP/TANF/FDPIR 
Foster Child 
Reduced 
 Reason for Denial:
Income too high  Incomplete App. 
Date Withdrawn
from School: _______________________
Denied
Signature of Determining Official ___________________________________________________________ Date Approved: ________________________
Signature of Confirming Official (Verification only) _____________________________________________ Date Confirmed:________________________
NE Department of Education – Nutrition Services
National School Lunch Program
Page 1 of 2
Free & Reduced Price School Meals Family Application – complete one application per household
Your children may qualify for
free or reduced price meals if
your household income falls
at or below the limits on this
chart.
Attachment C: 2013-14
FEDERAL INCOME CHART
for School Year 2013-14
Household size
Yearly Monthly Twice Every Weekly
per
Two
Month Weeks
1
21,257
1,772
886
818
409
2
28,694
2,392 1,196 1,104
552
3
36,131
3,011 1,506 1,390
695
4
43,568
3,631 1,816 1,676
838
5
51,005
4,251 2,126 1,962
981
6
58,442
4,871 2,436 2,248 1,124
7
65,879
5,490 2,745 2,534 1,267
8
73,316
6,110 3,055 2,820 1,410
Each additional
7,437
620
310
287
144
person:
Use of Information Statement: This explains how we will use the information you give us.
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 four digits of the social security number of the adult household
member who signs the application. The last four digits of the social security number are 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.
Non-Discrimination Statement: This explains what to do if you believe you have been treated unfairly.
“In accordance with Federal law and U.S. Department of Agriculture policy, this institution is
prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410 or call toll free (866) 632-9992
(voice). Individuals who are hearing impaired or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish). USDA is an
equal opportunity provider and employer.”
NE Department of Education – Nutrition Services
National School Lunch Program
Page 2 of 2