ANPO WICAHPI Student application

ANPO WICAHPI
Student

First NameLast Name
School Year
Grade
Last School Attended
School Phone Number
Date

MonthDayYear
Date
ANPO WICAHPI MUST HAVE A COPY OF YOUR CHILD'S:
- Updated Immunization Record
- CDIB or Proof of Tribal Membership
- State Certified Birth Certificate
- Social Security Card (Needed for Medical Records)
- Transcripts of Grades
- Health/Medical Insurance/Medacaid Card (If Covered)
- Court Appointed Parent or Legal Guardian MUST provide legal documentation
- Completed Anpo Wicahpi Application
- Tuition
Last Name
First
Middle
Preferred First Name
Lakota Name
Lakota Name Translation
Address

Permanent Address

Street Address Line 2

City/TownState

Zip
Home Telephone
Cell Phone (if any)
Message Number
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Applying for Grade
Current Grade
Tribal Affiliation
Date of Application

MonthDayYear
Date
Native language
Other language(s) spoken at home
Have you ever applied to Anpo Wicahpi?

YesNo
Do you have a sibling applying to Anpo Wicahpi?

YesNo
If yes, please tell us her name?
What is the academic school year you're applying for?
Mother
Address
Phone
Occupation
Work Number
Email
example@example.com
Father
Address
Phone
Occupation
Work Number
Email
example@example.com
Guardian
Address
Phone
Occupation
Work Number
Email
example@example.com
Is there a custody order in place? If so please attach a copy.

YesNo
Physical Address
Directions to your home
Candidate Project for Admission

Directions: To be completed by the candidate.
1. Why do you want to attend Anpo Wicahpi?
3. How does Lakol Wicohun (Lakota Lifeways) influence your life?
4. Describe the experience at your last school?
We certify that all information submitted in the admission process is factually accurate and honestly presented.
Candidate signature

Clear
Date

MonthDayYear
Date
Parent/Guardian signature

Clear
Date

MonthDayYear
Date
To be completed by parent(s) or guardian(s) at Anpo Wicahpi, we believe that the success of students is directly linked to the type of support and encouragement they receive from both their family and their school. We seek to form partnerships with our parents that will allow us to provide the best foundation of support for our students. The formation of that partnership begins during the application process. We hope you will answer the following question in a way that will help us get to know your child as well as possible.
What should we know about your student that would help ensure the best possible experience at Anpo Wicahpi?
2. Do you have knowledge of Lakol Wicohun (Lakota Lifeways, songs, prayers of the Oglala Lakota)?
3. Are you willing to be involved and participate in Lakol Wicohun activities on behalf of your students?
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Waiver of Liability

I (we) hereby grand permission for the above student to participate in any organized school sponsored activity trip as approved by Anpo Wicahpi.

I (we) understand the student will be properly chaperoned and all precautions will be taken to ensure his/her safety.

I (we) acknowledge that attending Anpo Wicahpi, means my child will be, on occasion, in an outdoor setting as an integral part of many of school's program. Student may be doing activities such as: exploring plants and animals (collecting, touching); and walking, hiking and running over and through a variety of terrain, including rocks, hillsides and wet areas, such as flowing creeks and ponds (wet areas) during their academic classes and on field trips. Any of these outdoor activities may, by their nature, expose children to a variety of hazards which could cause injury. This includes working with knives, awls, saws, and other sharp tools.

I am aware of the risks, conditions and hazards of the School's innovative learning activities, and I hereby release, discharge, and hold harmless the school, teachers, volunteers and other representatives from any claims or liability arising out of or relating to any injury (of any kind) that may result to my child while participating in these school sponsored sessions.

I verify that my child has no past or current physical condition that might affect their participation in the course, other than as described on the Medical Form. In the event my child is in need of emergency medical treatment, I hereby authorize the School staff or volunteers to obtain or provide emergency hospitalization, surgical, or other medical care for my child. I specifically indemnify and hold harmless the school, staff and volunteers from any negligence and all costs arising out of the decision to obtain and provide such care, treatment and/or procedure for such emergency.

The undersigned acknowledge the reading of the above and foregoing statements and fully understand the nature and consequence thereof.

Students who wish to participate in competitive sports must have a current physical on file before they can participate in sports activities.

I (we) hereby grant consent permission/authorization for the above students to participate in competitive sports sponsored by Anpo Wicahpi.

I (we) hereby grant permission to Anpo Wicahpi for use of the above student's photograph and name for public information or exhibit purposes deemed appropriate by representatives of Anpo Wicahpi. This includes Anpo Wicahpi web page internet displays. It is clearly understood that no royalty fee or other compensation of any character will become payable to me by reason of such use or release.
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
EMERGENCY AND HEALTH INFORMATION:
Student's Full Name
Date of Birth

MonthDayYear
Date
Social Security Number
Print Guardian's Name
Print Minor's Name
DO HEREBY AUTHORIZE ANPO WICAHPI TO:

Act in my behalf, in the best interests of the child, in authorizing medical care of behavior or mental health care for them. (To include any vaccinations, x-ray, laboratory, anesthetic, medical, surgical or dental diagnosis and/or treatment) care to be rendered to the above-named minor under supervision and upon advice of a physician, surgeon or dentist licensed to perform such care.

In giving this consent, I recognize and understand that in situations where the above-named minor required immediate medical or hospital care, it may not be possible to contact me. In such situations, I authorize a physician, surgeon, or dentist to exercise their professional judgement and assess risks incident to and choose the necessary treatment as their professional judgement determines to be necessary for the health or safety of the above-named minor.
Signature

Clear
Date

MonthDayYear
Date
Name of person who the student resides with:
Phone number:
Relationship to participant
Address
Employer: Work Phone
Employer
Email Address
example@example.com
Cell Phone
Name of emergency contact:
Relationship to participant
Emergency Contact who is Authorized to Pick Up Participant if Parents/Guardians Are Unavailable
Address
Employer: Work Phone
Employer
Email Address
example@example.com
Cell Phone
MEDICAL INFORMATION
Physicians name
Physician's Street address
City, State
Physician's Phone #
Dentist name
Address

Street address

Street Address Line 2

City, StateState / Province

Postal / Zip Code
Phone #
Date of Last Tetanus

MonthDayYear
Date
Known Allergies
Present Medications
Are there any dietary needs?
Are there any Conditions which could limit participation or result in emergency situation?
Are there any past surgeries, significant illnesses or diagnosis that staff should be aware of?
Other Medical Information we should be aware of
Insurance Company
Policy Holders I.D.
This consent will be in effect beginning (date)

MonthDayYear
Date
Please Provide a copy of child's health insurance card
Tuition Payment/Reimbursement

At Anpo Wicahpi Owayawa many of the Lakol Wicohun activities accumulate numerous expenses including, Inipi, Lowanpi, Isnati Awica Lowanpi. These activities are vital to your student's success. Please keep this in mind when providing tuition for the academic school year.
I (parent/guardian) name,
parent of (student name)
I am paying the tuition fee by the following:

1. I am paying the tuition fee of $100.00 via check, cash or money order. (please attach)2. Donate 1 load of inipi wood3. Donate 2 yards of red trade cloth4. Donate 4 large bags of flat tobacco for waunyeyapi and cangli pata5. Donate Large bag/bags of peji hota (sage), ceyaka, chokecherries, plums, cedar, etc.6. Donate Abalone shells, hair pipe bones, sinew, elk teeth, shawl fringe etc.
Parent or Guardians Signature

Clear
Date

MonthDayYear
Date
Student Dress Code Agreement

AWO is committed to teaching students to honor our ancestors and families at all times. Student appearance is no exception. Students' clothing should show respect for themselves, their families, and the school. AWO has implemented a Dress Code. With the aid of the AWO staff, the administration will determine if a student is complying.

Students are expected to make good choices prior to arriving at school SO that their clothing does not create an issue with the AWO dress code. More importantly, it is the parents' responsibility to make sure that their student is dressed appropriately for school. The AWO dress code applies anytime during school hours and at all activities sponsored by the school on or off campus. Students out of compliance with the dress code will be required to change their clothing. If they refuse to comply with the dress code further disciplinary action may occur.

During the School Year our students are required to comply with the dress code outlined. Students and their families will be responsible for purchasing school supplies and appropriate clothing attire. In cases where the student are not able to provide their own attire the school may assist.
- Students will wear long skirts that fall below the knee. Many students and families prefer ribbon skirts or other traditional style skirts, but maxi skirts are also acceptable.
- Shirts are not to have any innapropriate or derogatory logos or photos.
- Innapropriate and immodest clothing that reveals privcate areas of the body will not be allowed.
- If students are wearing sweaters, they are not to wear it over their head, and it cannot display any inappropriate or derogatory logos or photos. Preferably the sweaters are to be plain.
- Students are encouraged to wear traditional belt, wokpan, and knife sheath daily. Traditional jewelry is also encouraged.
- Students are not allowed to wear JEANS, except on special occasions. If they are caught in jeans they will be asked to change. If they do not comply further disciplinary action may occur
- Students are not to change out of their dress code at school sponsored events.
Student Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
Students Full Name
Date of Birth

MonthDayYear
Date
Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
Records to be disclosed. (Please check all)

Report CardsCopy of Birth CertificateSocial Security or copy of SS#Copy of Tribal Enrollment CertificateDiscipline/Behavioral HistoryStandardized Test ScoresHealth RecordsCurrent IEP (special Education/Speech)Talented and Gifted
Purpose of Disclosure:

Transfer inTransfer outParent RequestOther:______________
I hereby authorize you to release school records to:

Anpo Wicahpi, Pine Ridge Girls School

2237 BIA 27

Porcupine, SD 57772

Phone: 605-455-1218 Fax: 605-455-1812
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
School Checkout Form
Student Name
At the beginning of each year, the parents/guardians are required to sign an acknowledgement of
1. Student checkouts during the academic day are limited to the parent/legal guardian. Individuals who are not the parent/guardian will not be allowed to check students out during the academic day unless requested by the parent/guardian in writing.
2. Individuals must be 25 years or older to be added and approved to a student's checkout list. Individuals who fail to comply will be removed from the student checkout list. Permission notes will be accepted and approved at the administration's discretion.
3. This checkout form will be enforced at all school sponsored events and including overnight trips.
4. All consent to check-out student must be given in writing. Anpo Wicahpi will not consider over-the-phone consent valid.
5. Students will be dropped off where they are picked up unless the parent or guardian contacts the Head of School prior to dismissal.
Student Checkout Information (Must be 25 years of age or older) Provide the name and relationship of individuals who you are giving consent to check out your child.
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

ANPO WICAHPI

EMERGENCY AND HEALTH INFORMATION:

MEDICAL INFORMATION

AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

School Checkout Form