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:
Month:

Day:

Gender/Orientation:
Male ( )
Female ( )
Self-identify as
Prefer not to respond (

Year:

Place of Birth:
City:
State:

Zip Code:

)
Verified by:

Tribal Affiliation:

Degree of Indian Blood:

Enrollment Number:

Home Agency:

Primary language spoken in the home:
(1)

Secondary language spoken in the home:
(2)

2. FAMILY INFORMATION
Father:

Mother:

Address:

Address:

Home Agency:

Home Agency:

Tribal Affiliation:

Tribal Affiliation:

Enrollment Number:

Enrollment Number:

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Living: ( )

Deceased: (
Date:

)

Living: ( )

Deceased: (
Date:

Occupation (Optional):

Occupation (Optional):

Employer:

Employer:

Home Telephone:

Home Telephone:

Work Telephone:

Work Telephone:

Cellular Telephone:

Cellular Telephone:

Emergency Contact:

Emergency Contact:

Other (Specify):

Other (Specify):

Legal Guardian:

Other (Group Home, etc.):

Address:

Address:

Home Agency:

Telephone:

Tribal Affiliation:

Student Lives With:

Enrollment Number:

Home Telephone:

Occupation (Optional):

Work Telephone:

Employer:

Cellular Telephone:

Home Telephone:

Emergency Contact:

Work Telephone:

Other (Specify):

)

Cellular Telephone:
Emergency Contact:
Other (Specify):

3. SCHOOL(S) PREVIOUSLY ATTENDED
School Name:

Dates Attended:

Address:
City:

Reason(s) for Leaving:
State:

Grades Completed:

Zip Code:

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OMB Control No. 1076-0122
Expires: XX/XX/XXXX

School Name:
Address:
City:

Dates Attended:

Grades Completed:

Reason(s) for Leaving:
State:

Zip Code:

School Name:

Dates Attended:

Address:
City:

Reason(s) for Leaving:
State:

Grades Completed:

Zip Code:

I am legally responsible for this student and hereby apply for their admission to this school. I
understand that additional information may be requested by the school before the student is enrolled.
Parent/Legal Guardian/Adult Student Signature:
Date:
Day School Enrollment:
Approved ( )
Not Approved (
Principal Signature:

)
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

Social 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

In their 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

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Approved Date:
In-Boundary
(Signature & Title of Approving Official)

Approved Date:
Out-of-Boundary
(Signature & Title of Approving Official)

Off-Reservation Boarding School
(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;9989; 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
1.

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.

Gender/
Orientation:

Indicate whether the student is male, female, self-identifies as, or prefer not to
respond.

Tribal Affiliation:

List the tribe(s) in which the student is enrolled.

Degree of (cont..)

Continued on next page

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OMB Control No. 1076-0122
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Indian Blood:

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 they are 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.

Primary language
spoken in the
home:

Enter primary language spoken in the home.

Secondary
language spoken
in the home:

Enter secondary language spoken in the home.

2.

FAMILY AND BACKGROUND INFORMATION

Parents’ Name
Father’s Address:

Enter father’s address if different from students.

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.

Telephone
Numbers:

Please list father’s home telephone, work number, cellular 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.

3. 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.
4. FOR BUREAU USE ONLY: Self-Explanatory.

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