Siletz news letter., June 01, 1994, Page 4, Image 4

Income Guidelines for JOM & Adult Ed.
Confederated Tribes of Siletz
ADULT EDUCATION APPLICATION
Family size and income Eligibility scale for assistance*
Please ComDlete All Sections
Family size
Maximum Yearly Income
1 .......................................... $
9,213
2 ................................................
12,432
3 ................................................
15,651
4 ................................................
18,870
5 ................................................
2 2 ,0 8 9
6 ................................................
25 ,3 0 8
7 ..................
2 8 ,5 2 7
8 ................................................
31 ,7 4 6
Each Additional
Family Member.........................................
3,219
*Special Circumstances will be considered regarding income
eligibility for assistance.
ADULT EDUCATION
Name of ADDlicant
Roll#
Phone
Social Security #
Class Requested (Title)
Name and Address of School, Organization or person offering
this class:
Please list all required costs of enrolling in this class:
Thank you,
Rena Philbrook
Education Specialist
APPLICATION FORM
JOHNSON O'MALLEY PROGRAM
$
Other Costs
$
Total
$
Date
FOR OFFICE USE ONLY
Messaae Phone
APPROVED
or Blood Degree
SIGNATURE
School Attendina
Roll #
Father
Roll #
Student Resides with: (Name & Relationship)
EMERGENCY CONTACT INFORMATION: In case of an emergency,
Please contact:
AMOUNT
TITLE
SURVEY
S U B JE C T :
Mother
DENIED
DATE
Grade
School Address
Street Address
Books/Supplies
List all other required costs:
Home Phone
Tribal Affiliation(s)
Name
$
ADDlicants Sianature
County of Residence
Roll #
Tuition or Fees
Date
Address
Date of Birth
Msa. Phone
Address
Adult education is for the enhancement of job-related
skills and to further adult basic education. The Johnson
O'Malley adult education program has the ability to help those
who need financial and educational assistance in obtaining their
personal/educational goals. If you would like more information
on our program please feel free to call 444-4263.
Student Name
Age
C A T E R IN G S E R V IC E
IN
S IL E T Z
OREGON
IF
YOU WERE TO HAVE A C A T E R IN G S E R V IC E I N
S IL E T Z
D E L IV E R IN G
FOOD
AND
D R IN K
IN
THE
MORNING
AND
THE
AFTERNOON
WOULD
YOU
BE
IN T E R E S T E D ?
YES ____
NO ____
I F SO P LE A S E IN D IC A T E WHAT YOU WOULD W IS H TO
BE A V A IL A B L E ON BOTH THE MORNING MENU AND THE
AFTERNOON LUNCH MENU.
MORNING MENU
1.
LUNCH
1.
2 .
2 .
3.
3.
4.
4.
5
5.
Relationship
Phone
PLEASE LIST ANY ILLNESSES OR MEDICAL CONDITIONS THAT MAY
AFFECT STUDENT PARTICIPATION IN THE JOM PROGRAM:
Please list other children in the household: (Name & Age)
P LEASE
RETURN
TO
SHARON
H EALTH C L I N I C , T H A N K S .
R IC K E T T S
AT
THE
.........
...................................-