LAKE VIEW HIGH SCHOOL
4015 North Ashland Avenue | Chicago, Illinois 60613
Telephone 773.534.5440 | Fax 773.534.5585 | www.lakeviewhs.com
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Scott Grens, Principal | Angela Newton, Assistant Principal | Meghan Sovell, Assistant Principal | Toney Vast-Binder, Assistant Principal
LVHS SCHOOL FEE PAYMENT PLAN
Adopted SY15-16
DATE:____________
STUDENT NAME:___________________________________
HOMEROOM:_____________________
PARENT NAME:____________________________________
PHONE NUMBER:__________________
FAMILY SIZE: ADULTS OVER 18____________
CHILDREN UNDER 18_______________
FAMILY INCOME FROM ALL SOURCES
AMOUNT (SPECIFY PER MONTH, PER YEAR, ETC.
NUMBER OF CHILDREN CURRENTLY IN SCHOOL:______________________
NUMBER OF CHILDREN CURRENTLY ELIGIBLE FOR FREE BREAKFAST OR FREE LUNCH PROGRAM:____________
Please explain factors/expenses affecting family income and inability to pay student fees:
PAYMENT PLAN AGREEMENT:
__________________________________________
PARENT NAME (PRINT)
______________________________________
PARENT SIGNATURE
__________________________________________
TELEPHONE NUMBER
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ADDRESS
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