477-JOM STUDENT APPLICATION
477-Johnson O'Malley is a federal program whose main objective is to ensure Indian children receive educational opportunities that would not otherwise be provided through the public school system. JOM is a supplemental program providing special services to Indian students based on the needs of individual communities.
477-Johnson O'Malley requires eligible American Indian and Alaska Native students to be at least one of the following:
An enrolled citizen of a federally recognized tribe OR at least 1/4
th
or more degree of Indian blood descendant of a member of a federally recognized Indian Tribe.
Children between the ages of 3 through grades 12
th
who are enrolled in school.
Please attach a copy of student's CDIB, tribal enrollment membership, or proof stating the student is at least 1/4
th
or more degree of Indian blood descendent of a member of a federally recognized Indian Tribe.
The 477-JOM program serves all Native American enrolled students attending school in the Pawnee Nation Jurisdiction. Those schools include:
Cleveland
Glencoe
Jennings
Pawnee
Yale
EPIC
Please be advised that all student files and 477-JOM applications must be updated and completed each school year to be qualified to be a part of the 477-Johnson O'Malley program.
Updated 7.10.26
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Johnson O'Malley Program
477-JOM STUDENT APPLICATION
School Attending: (Please circle)
Cleveland
Glencoe
Jennings
Pawnee
Yale
EPIC
Date:
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Grade Entering:
Student Name:
Birth date:
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Mailing Address:
Dirección de la calle
Dirección de la calle Línea 2
Ciudad
Estado / Provincia
Código Postal / Zip
Parent/Guardian Telephone Numbers:
Format: (000) 000-0000.
CDIB/Tribal Enrollment ID Card#
Enrolled Tribe:
CDIB/Enrollment card attached? (MUST BE PROVIDED)
*
Y:
N:
Parent/Guardian Information
Check here if the address is the same as student:
Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Address:
Email Address:
ejemplo@ejemplo.com
2026 - 2027 SCHOOL YEAR
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P.O. Box 470 • Pawnee, Oklahoma 74058 • Phone: 918-762-3227
Johnson O'Malley Program
477-JOM STUDENT APPLICATION CONTINUED
Needs Assessment Surveys are beneficial to Indian Education and is used in determining the needs of all eligible students.
1. Tutoring
2. Parental Participation
3. Cultural Enrichment
4. Career/Job orientation
5. Counseling
6. Other (Use space below to explain)
7. Academic Needs (math, reading, etc.)
Please rank the three most important needs (Example: 5,4,7)
Education Plan: Please list any and/or all goals you would like to achieve/see your child achieve for this new school year. An example can be: More reading, obtaining a 4.0 GPA, learning the difference between lower case and upper case alphabets, etc.
Plan of Action:
Plan of Action:
Rows
Goal/Activity
1.
2.
3.
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477-JOM STUDENT APPLICATION CONTINUED
ACADEMIC AUTHORIZATION
The Pawnee Nation Youth Services and Johnson O'Malley Parent Committee has my permission to obtain grades and attendance records from my child/children's teachers for purposes solely to provide educational support and incentives.
ACADEMIC AUTHORIZATION
YES:
NO:
PHOTO AND NAME RELEASE
I give my consent for the Pawnee Nation 477-Johnson O'Malley Program to take pictures of my child and give my permission to release names and photos for JOM activities.
PHOTO AND NAME RELEASE
YES:
NO:
Print Parent/Guardian Name
Date
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
Parent/Guardian Signature
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UPLOAD A COPY OF YOUR CDIB CARD HERE:
*
Preview PDF
Submit
Should be Empty: