Fillable Ada Ardmore Sulphur Tishomingo (The Chickasaw Nation)

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Ada Ardmore Sulphur Tishomingo (The Chickasaw Nation)

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Early Childhood Program Application
□ Ada □ Ardmore □ Sulphur □ Tishomingo
□ Federally recognized tribal documentation □ Insurance/Sooner Care
□ Current immunization record □ State birth certificate
□ Income documentation □ Disability documentation
Child’s Information
Name: Gender: Female Male
First Middle Last Suffix
Birth date: Age: Public school district:
Native American Indicate tribal affiliation:
Caucasian African-American Hispanic Other:
Primary Parent/Guardian Information
Name: Relationship to child:
First Middle Last Suffix
Address: Birth date:
Street City State ZIP
Email: Chickasaw Nation employee? Yes No
Home phone: Cell phone: Work phone:
Secondary Parent/Guardian Information
Name: Relationship to child:
First Middle Last Suffix
Address:
Street City State ZIP
Email: Chickasaw Nation employee? Yes No
Home phone: Cell phone: Work phone:
Family Status (check what best describes your situation)
Family status: Income/benefit: Number in household:
Single, head of household, never been married Unemployed
Divorced Paid weekly
Separated Paid bi-weekly Mother’s name (guardian)
Married Paid monthly
Widow Other income:
Common law Father’s name (guardian)
THE FOLLOWING DOCUMENTATION MUST ACCOMPANY A COMPLETE AND SIGNED
APPLICATION TO BE CONSIDERED FOR ENROLLMENT.
Education Division / Early Childhood
300 Rosedale Road / Ada, Oklahoma 74820 (580) 421-7711 / (580) 436-7279
Bill Anoatubby
Governor
Page 1 of 2 Form no. 04466 CS-EDU Rev. 3/2018
Persons in Household
Name
Relationship to child
Age
Additional Information
Are there any hardship conditions in your family at this time?
□
Yes
□
No
If yes, please describe:
_________________________________________________________________________
____
________________________________________________________________________________________
Does your child have a documented disability or special need (speech, IEP, IFSP, etc.)? □ Yes □ No
If yes, please attach supporting documentation.
Please address in detail any educational, medical, social or emotional concerns you have for your child.
____
________________________________________________________________________________________
____
________________________________________________________________________________________
Does your child require transportation to/from school? □ Yes □ No
Has any member of your immediate family been a Chickasaw Nation Head Start or Early Childhood Program
participant?
□ Yes □ No
I
certify that the information that I have submitted is true to the best of my knowledge and realize it is
subject to verification, and that falsification is grounds for immediate termination and may subject me to
prosecution under law. I allow the release of information for verification and reporting purposes.
____
____________________________________ _________________________
Parent/guardian signature Date
________________________________________ _________________________
ERSEA manager Date
□ Federally recognized tribal documentation □ Eligible for enrollment
□ Birth certificate □ Added to waiting list
□ Immunization record
Insurance/Sooner Care
Page 2 of 2 Form no. 04466 CS-EDU Rev. 3/2018
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Ada Ardmore Sulphur Tishomingo (The Chickasaw Nation)

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Completed 31 January 2021

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