Siletz news /, May 01, 2005, Page 8, Image 8

TRIBAL PROGRAM NEWS
Siletz Tribal Head Start Enrollment Application
Return this application to: Siletz Tribal Head Start, PO Box 549, Siletz, OR 97380-0549
For more information, call 1-800-922-1399 or 541-444-8376 2005-06 year
2. SSN:
1. Child’s Name:
3. Child’s Sex: M
F (circle one)
Returning Student
Age:
No
Yes
4. Date of Birth:
5. Does your child have any condition that may be considered a disability or special need? No.
Yes
(please attach verification)
Please explain:
6. Is child member/descendant of a federally recognized Indian Tribe? No
Yes
(please attach verification)
Tribe(s)
Roll #
All children get to steer the
Sternwheeler, including Captain Troy
Primary language spoken in the home:
7. Parent/Guardian( 1 ):___________________________________ —------------------------
Date of Birth:SSN:--------------------- --------------------
Street and Mailing Address: _____--------------------------------------------------- --------------
City:
Telephone: Home:(
ZIP:
State:
)Work:(
)------------------------------ Messaged
)---------------------------------
Ilario, Eva, Kray, and Josué enjoy the
Sternwheeler ride.
Parent/Guardian(2):------------------------------- - -----------------------------------------------------
Date of Birth: SSN:----------- ------------ ------------------
Street and Mailing Address:________________________________ _ ________________
City:
Telephone: Home:(
State:
)Work:(
ZIP:
Highlights from
Siletz Tribal
Head Start
)------------------------------ Messaged
8. A preference for enrollment can be given to families that face any of the following conditions: single parents, parents separated/
divorced, child is a victim of abuse or neglect, or child suffers from a non-handicapping condition.
If your family meets this criteria and you would like to claim that preference, please list the conditions here:
9. List all other household members by name and date of birth:
I.
2--------------------------------------------------------
3
4--------------------------------------------------------
5.6--------------------------------------------------------
Salem Head Start students Troy, Oscar,
Juan, and Randall Jr. go on a field trip
to the Sternwheeler.
10. Financial Statement: Monthly Income (you must attach verification of these benefits)
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 regardless of race, age, sex, handicap, or
national origin. Any person who believes he/she has been discriminated against should write to the Secretary of Agriculture,
Washington, D.C. 20250.
8
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Siletz News
•
May 2005
Parents Eric, Bryce, and Rual help get
the Salem center ready for new siding.