Student Enrollment Application for students enrolled in

OMB Control No. 1076-0122

Expires: XX/XX/XXXX

STUDENT ENROLLMENT APPLICATION

FOR STUDENTS ENROLLED IN BUREAU-FUNDED SCHOOLS

Name of School:
Type: Day School ( ) Boarding School ( ) Peripheral Dormitory ( )	Funding: Pub. Law 100-297 Grant ( ) Pub. Law 93-638 Contract ( ) BIA Operated ( )
1.IDENTIFICATION
Name of Student: (Last) (First) (Middle)
Address: P.O. Box Street: City: State: Zip Code Miles from home to school:
Date of Birth: Place of Birth: Month Day Year Sex: Male ( )Female ( ) Verified by:
Tribal Affiliation: Degree Indian: Enrollment Number: Home Agency: Dominant language spoken in the home: (1) (2)
2. FAMILY INFORMATION Father: Address: Tribal Affiliation: Home Agency: Enrollment Number: Living: ( ) Dead: ( ) Occupation (Optional): Employer: Telephone Home: Work: Emergency: Other (specify)	Mother: Address: Tribal Affiliation: Home Agency: Enrollment Number: Living: ( ) Dead: ( ) Occupation (Optional): Employer: Telephone Home: Work: Emergency: Other (specify)

Legal Guardian: Address: Tribal Affiliation: Home Agency: Enrollment Number: Occupation (Optional): Employer:	Other (group home, etc): Address: Telephone: Student Lives With: Telephone Home: Work: Emergency: Other (specify)
SCHOOL(S) PREVIOUSLY ATTENDED:
School Name: Dates Grades Attended: Completed: Address: Reasons for Leaving: City / State:
School Name: Dates Grades Attended: Completed: Address: Reasons for Leaving: City / State:
School Name: Dates Grades Attended: Completed: Address: Reasons for Leaving: City / State:
I am legally responsible for this student and hereby apply for his/her admission to this school. I understand that additional information may be requested by the school before the student is enrolled. Signature of Parent/Legal Guardian/Adult Student Date
Day School Enrollment: Approved: Not Approved: Principal Date

4. CRITERIA FOR BOARDING OR OUT OF BOUNDARY ENROLLMENT: Favorable action is recommended upon this application because this case conforms to the following criteria for boarding school or out of boundary enrollment. If this application is for an off reservation boarding school and for social reasons, a social summary is to accompany this application.

Education Factors Federal/Public schools near student’s home: ( ) Do not offer grade level ( ) Are severely overcrowded ( ) Do not offer student’s grade ( ) Exceed 1½ miles walking distance to school or bus route ( ) Do not offer special vocational/ preparatory training necessary for gainful employment ( ) Do not offer adequate provisions to meet academic deficiencies or linguistic/cultural differences ( ) Receiving School offers special academic program needed by student Approved: Date: In Boundary (signature & title of approving official) Off-Reservation Boarding School (signature & title of approving official)

Social Factors In his/her environment, the student: ( ) Was rejected or neglected ( ) Does not receive adequate parental supervision ( ) Well being was imperiled due to family behavioral problems ( ) Has behavioral problems too difficult for solution by family or local resources ( ) Has siblings or other close relative enrolled who would be adversely affected by separation Approved: Date: Out-of- Boundary (signature & title of approving official)

Privacy Act Statement: This information is collected as provided by 5 U.S.C. 552A. The Office of Indian Education Programs is authorized to collect this information in accordance with Public Law 95-561; 98-511;99-89; and 100-297. The information will be used to determine the level of funding to be distributed by formula to BIA funded elementary and secondary schools. Weighted student units, the value of basic and specialized instructional and residential programs, are used to calculate the distribution of funds. The information may be disclosed to appropriate Department of the Interior and Congressional Offices for policy and budgetary purposes.

Paperwork Reduction Act Statement: This information is collected to identify each student’s instructional and residential program classification. It will be used to allocate appropriated funds on a weighted student unit formula. The information is supplied by the respondent to obtain or retain a benefit, that is, to provide appropriate schooling and the needed funding. It is estimated that this form will take an average of 15 minutes to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the form, please send them to Attn: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. The control number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB control number.

Instructions for Completing the Student Enrollment Application Form

IDENTIFICATION
Name:	Enter the name of the student by last, first, and middle. Example: Green, Frances Jean
Address:	Enter the address where student receives mail.
Date of Birth:	Enter the student’s date of birth.
Verified by:	The school is responsible for filling in this section. Verification of birth date may be done by birth certificate, affidavit, baptismal record, etc.
Place of Birth:	Enter the location, name of city or town, and state where the student was born.
Sex:	Indicate whether the student is male or female.
Tribal Affiliation:	List the tribe(s) in which the student is enrolled.
Degree Indian:	Indicate such as: 4/4, 3/4, ½, 1/4, etc.
Census Number:	Enter the census number or roll number assigned to the student by the governing Tribe or Agency in which he/she is a member/enrolled.
Home Agency:	Enter the name of government office which has the responsibility or list of enrolled members which includes the student’s name.
Dominant language spoken in the home:	Enter dominant language spoken in the home.

FAMILY AND BACKGROUND INFORMATION
Parents’ Name
Father’s Address:	Enter father’s address if different from student’s.
Tribal Affiliation:	Enter father’s Tribe.
Home Agency:	Enter Agency where father is enrolled.
Census Number:	Enter father’s census number.
Living / Deceased:	Indicate whether father is alive or deceased, entering date if deceased.
Occupation (Optional):	Enter father’s occupation.
Employer:	Enter the name of father’s employer or where he works.
Telephone Numbers:	Please list father’s home telephone, work number, an emergency number or other numbers where father can be reached, in case of an emergency. If other, indicate friend, aunt, uncle, etc.
Mother:	Same instructions as above.
Legal Guardian:	Same instructions as above.
SCHOOLS PREVIOUSLY ATTENDED: List the names, addresses, dates, grades completed and reasons for leaving all the schools the student previously attended. Please fill out as accurately as possible.
FOR BUREAU USE ONLY: Self-Explanatory.

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