Siletz news /, June 01, 2002, Page 8, Image 8

TRIBAL PROGRAM NEWS
Siletz Tribal Head Start
Enrollment Application
Return this application to: Siletz Tribal Head Start, P.O. Box 549,
Siletz, OR 97380. For more information, call 1-800-922-1399, ext. 264, or
541-444-8264.
Child’s name: 2. SSN:_______=______ -
Child’s sex: * M * F
Returning student: *
-Yes
* No
Child’s date of birth://
Does your child have any condition that may be considered a disability or
special need? * No * Yes, explain:
___________________________________ (please attach verification)
6. Is child member/descendent of a federally recognized Indian tribe? * Y * N
Roll #:------------ Tribe(s):(please attach verification)
7. Parent/Guardian (1):SSN:_____ r______ -
Street and mailing address:________________________________________
C i ty/S tate/ZI P:__________________________________________________
Telephone (h):(w):(msg):
Parent/Guardian (2):SSN:______ =______ -
Street and mailing address:________________________________________
C i ty/S tate/ZI P:_ ________ ______ ________________________________
Telephone (h):(w):(msg):
1.
3.
4.
5.
8. A preference for enrollment can be given to families that face any of the
following conditions: single-parent household, parent separated or divorced,
child is a victim of abuse or neglect, or child suffers from a handicapping
condition. If your family meets this criteria and you would like to claim that
preference, please list the condition(s) here:
9. List all other household members by name:
1.
3.
5.
2.
4.
6.
10. Financial statement (you must attach verification of these benefits). Check
all that apply:
*
*
*
*
Employed
* Unemployment
Child Support
* TANF
Social Security
* Disability
Other, explain:__________________
* General Assistance
# Veteran’s Benefits
* College grants/scholarships
11. With my signature I certify that the above information is accurate:
Signature: Date:
For office use only
Date received:Staff initials:
Siletz Tribal Head Start is an equal opportunity program and open to
all children regarles of race, age, sex, handicap, or national origin. Any
person who believes he/she has been discriminated against should write
to: Secretary of Agriculture, Washington, DC 20250.
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Solete News - Oy June2002