PPS FOCUS OPTION LOTTERY
CONFIDENTIAL INCOME ELIGIBILITY FORM

Students who attend a Head Start Pre-K or qualify for free and reduced-price meals receive preference for admission to eleven focus option and immersion programs listed on the back of this page. To qualify for the preference, complete this form and a Focus Option Lottery application by March 9, 2016. MOST PROGRAMS HAVE ADDITIONAL ADMISSION REQUIREMENTS. Call the school or Enrollment & Transfer Center (ETC) at 503-916-3205 for more information.

This confidential form will be used only by ETC staff to determine lottery preference eligibility. It will not be shared with other departments or used to determine meal eligibility. All forms will be destroyed at the end of the lottery cycle.


STUDENT LAST NAME:______FIRST NAME:______

DATE OF BIRTH:______STUDENT PPS ID# or LOTTERY CONFIRMATION # (if known):______

PARENT CONTACT PHONE/E-MAIL:______

HEAD START: If your child currently attends a Head Start Pre-K complete this section. You do not need to provide your household income information.

PROGRAM NAME:______CONTACT NUMBER:______

By checking this box, I give permission for ETC staff to verify my child’s enrollment in Head Start.

If your child is not currently enrolled in a Head Start Pre-K program, please complete the section below.

ETC staff will determine whether the income listed qualifies for Federal Free and Reduced Price Meals, as shown below. ETC will randomly contact families for additional information to verify income status.

List all household members, including those who are not income-earners / Monthly earnings and wages before deductions / Monthly child support, welfare and alimony received / Monthly pensions, social security and retirement received / Other monthly income, including unemployment and workers comp. / Check if no
income

Federal Income Eligibility Guidelines, 2015-2016

The table below shows maximum monthly income for families to qualify for Reduced Price Meals. Families whose incomes are within
these guidelines qualify for preference to ten focus option/immersion schools and programs.
For more information visit http://portland.schoolwires.net/Page/2435.
Members in household / Monthly income to qualify for Reduced-Price Meals
2 / $2,456
3 / $3,098
4 / $3,739
5 / $4,380
6 / $5,022
7 / $5,663

By checking this box, I certify (promise) that all the information in this application is true and that all income is reported. I understand that if I purposely give false information my child will lose his/her lottery slot.

By checking this box, I understand that I must fill out a separate application to receive free and reduced-price meals.