Image provided by: University of Oregon Libraries; Eugene, OR
About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (June 1, 2008)
TRIBAL PROGRAM NEWS Siletz Tribal Head Start Enrollment Application - Return this application to: Siletz Tribal Head Start, P.O. Box 549, Siletz, OR 97380-0549. For more information, call 800-922-1399, ext. 1376, or 541-444- 8376. 2008-09 year Soc.Sec. # 1. Child's Name___ 2. Child’s Sex: MF 3. Child’s Date of Birth: Returning Student Yes__ No___ / /_____ 4. Does child have any condition which may be considered a disability or spe cial need? No__ Yes___ Explain:__________________________________________________________ (Please attach verification) 5. Is child descendent/member of a federally recognized Indian Tribe? Yes___ No___ Roll #________ Tribe_________________________ (Please attach verification) 6, Parent/Guardian Name(s) I_____________________________________________ Soc. Sec. #___________ 2.__________________________________________ Soc. Sec. #____________ Street Address_________________________ City___________ ZIP________ Mailing Address________________________ City___________ ZIP_______ Telephone #s: Home____________________ Work_____________________ Message______________________ Above: Teacher Tony keeps an eye on children in the water as Head Start students from Siletz visit the Toledo pool. Right: A Head Starter shows off the latest in life jackets. (photos by Tracey Worman) 7. Bus pick-up and drop-off address if different from above: _______________ 7 Dear Siletz. Tribal Head Start Applieant, Thank you for your interest in the Siletz. Tribal Head Start program. We are currently accepting applications for the Fall 2008 school year. Siletz Tribal Head Start has classrooms in Siletz. Salem. Springfield and Portland. Please complete the attached enrollment application and return it as soon as possible. You will be notified during August 2008 if your child was accepted into the program or placed on our waiting list. Every effort is made to provide daily transportation for all children enrolled in our program. However, due to considerations such as distance, time and ap propriate practice, you could be asked to self-transport should it be necessary to maintain a safe, efficient bus route. Please return the following documents with your completed application: 1. Documentation of family income from all sources. It may consist of: a. Cur rent payroll check stub(s) for one month; b. TANF award statement or copy of current check; c. Foster care award statement or copy of check; d. Annual income tax or W-2 statement(s); e. Self-employment or business statement; f. Social Security or SSI award statement; g. Unemployment benefits state ment or copy of check. (Income verification is mandatory for all families.) 2. If applicable, documentation of child’s enrollment or descendency in a fed erally recognized Indian Tribe. It may consist of: a. Copy of Tribal ID; b. Certificate of Indian Blood (C1B); c. For descendency, copy of Tribal ID, C1B or other documentation that verifies enrollment of parent, grandparent, great-grandparent, etc. and birth records that show lineage back to child. (Indian preference cannot be given unless verified.) 3. If applicable, documentation of child’s diagnosed disability. It may consist of: a. Copy of Individual Family Service Plan (IFSP); b. Letter or statement from qualifying agency stating your child meets this definition; c. Letter or note from physician or other qualified health provider. (Disability prefer ence cannot be given unless verified.) 4. Copy of child's immunization record. (Note: This is required before any child can attend class.) 5. Completed health and physical exam summary, signed and dated by physi cian. (Note: This is required within 45 days - after - the child is enrolled.) For your application to be fully complete, all of the above items should be attached. If you have any questions, please feel free to contact me by telephone at 800-922-1399. ext. 1376, or 541-444-8376. In partnership with children and families, DeAnn Brown, Director Siletz. Tribal Head Start 6 • Siletz News • June 2008 8. A preference for enrollment can be given to families that face any of the following conditions: single-parent household, parents separated or divorced, child is a victim of abuse or neglect or child suffers a non-handicapping medical condition. If your family meets these criteria and you would like to claim that preference, please list the qualifying condition(s) here: ____________________ 9. List all other household members by name and date of birth: Total # household members_______ 1.________________________________ 3.________________________________ 5.________________________________ 2.___________________________ 4.___________________________ 6.____________________________ 10. Financial Statement (you must attach verification of these benefits). Check all that apply: Employed ____ Unemployment ____ General Assistance ____ Child Support ____ TANF_____________ ____ Veteran’s Benefits ____ Social Security ____ Disability Other, explain ____College Grants/Scholarships Total Gross Monthly Income $_____________ (You must attach verification) 11. With my signature I certify that the above information is complete and accurate: Date:________ Signature: Siletz Tribal Head Start is an equal opportunity program and open to all children regardless of race, color, age, sex, handicap, or national origin. Any person who believes she/he has been discriminated against should write to the Secretary of Agriculture, Washington. D.C., 20250. Restoration CD Available If you attended the Restoration Celebration, you saw a CD of Tribal history and old photos that was played during the event. We are making that CD available to Tribal members at no cost. You need to fill out a request form (available on the Tribal Web site - www.ctsi.nsn.us) and send it to Diane Rodriquez, c/o Confederated Tribes of Siletz Indians. P.O. Box 549, Siletz. OR 97380-0549. The CD is restricted to one per Tribal member and each Tribal member must request their own. For questions, please call Diane Rodriquez at 800- 922-1399, ext. 1291, or 541-444-8291.
