Cheyenne and Arapaho Tribes

Johnson O'Malley Program Application

Please Check One:*

School District*

Other options, please list below*

Out of Service AreaOut of StateOther

Student's Name*

Last NameFirst Name

Gender:*

FemaleMale

Grade*

Date of Birth*

Example: "04/23/2020"

Tribal Affiliation*

Example "Cheyenne and Arapaho"

Please upload CDIB/Tribal Membership/Birth Certificate*

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Tribal Membership Card & Birth Certificate Pics Only, No Food Pics

Name of School Attending*

Example: "Roblyer Middle School"

T-Shirt Size:*

*New students must submit a copy of your Tribal Membership to the JOM Program before any services can be provided for your child or children.

*Descendent Student-Must submit a copy of parent or grandparents tribal membership, and copy of child's birth certificate to show relationship to enrolled parent or grandparent.

Parent/Guardian Signature: This completed application will also serve as a Release of Information to Public School Personnel giving my consent to release any school information regarding my child, as requested by the JOM Coordinator or JOM contact person. I give consent for the Cheyenne and Arapaho Tribes Johnson O'Malley Program to take pictures of my child and give my permission of release of photos for JOM activities.

Print Parent/Guardian Name*

Phone Number*

Area CodePhone Number

Email Address*

example@example.com

Address*

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian's Signature*

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All families must complete one Needs Assessment Form please see link &/or QR code below.

https://form.jotform.com/251326436621149