Certification Statement and Information Release
I, __________________________(print name) declare that the information provided by me on this application is true, correct and complete
to the best of my knowledge and that if granted assistance I will use the funding only for educational purposes. I understand this service is
provided due to the COVID-19 pandemic and in response to remote learning requirements. I understand that SCR staff will be verifying my
student’s utilization of this printer by doing assigned homework and staying in contact with his/her teachers. If the printer is not being
utilized for these purposes, I will be denied services. I understand that I will be requested to repay, through legal means, all or a portion of
the assistance granted if the funds are not used for the stated purpose. I give my permission for all information on this form to be shared
between the Ho-Chunk Nation, my State of Residence and any other pertinent agency or organization. I also give the Ho-Chunk Nation
Education Department and its staff, permission to contact any or all school officials, persons or other individuals regarding this request for
the purpose of gathering information to determine grant status, approval and program compliance. If the circumstances surrounding this
application change, including the amount of funding eligibility, I will immediately inform the Pre K-12 Educational Grant Program.
Parent/Guardian Signature _______________________________________________ Date ______________
Program Compliance and Appeal Acknowledgement
I, __________________________ (print name) understand that the Pre K-12 Educational Grant Program is a supplemental funding program.
I also understand that as a parent/guardian, I maintain sole responsibility for meeting my child’s entire educational funding needs. I further
understand that all applications are subject to approval and funding availability. I also understand that funding for this program is limited and
therefore is awarded on a first come, first served basis. Incomplete applications will not be considered and I understand that it is my
responsibility to make sure that I complete and provide all requested information. I also understand that applications that are incomplete or
are missing some or all of the requested information will not be processed until all the information is submitted by me to the Pre K-12
Educational Grant Program staff. I understand that I will be notified by letter, email or telephone of any missing or insufficient information
that is required in order for my application to be processed. The Ho-Chunk Nation is not responsible for application completion, information
gathering, vendor contacts or any other parent/guardian/applicant responsibilities with regard to the application for grant benefits as outlined
in the COVID-19 Relief Response Printer Purchase guidelines.
I further understand that in the event that I have complied with all Program Guidelines and deadlines and I submitted all requested
information and I my application is denied for reasons other than non-compliance or a lack of funding, I may appeal that decision and that I
must do so in writing, through certified mail at each level to the follow staff members within the prescribed timeframe. Within 5 business
days of the receipt of a decision I must contact the Division Manager with my appeal. The Division Manager has 5 Business days to send a
respond to my appeal. If I do not receive a response within 7 business days from the date my grievance was received by the Division
Manager I may file my appeal with the Executive Director of Education. The Executive Director of Education will respond to my appeal
within 10 business days IF it is the decision of the Executive Director of Education to overturn my denial. I understand that the Executive
Director of Education has the final authority in the decision process and if I do not receive a response within 12 business days from the date
my appeal was received by the Executive Director of Education, I must accept that my appeal was not granted. If I discuss my appeal in a
public, political or external forum I grant the Education Department and the Pre K-12 Educational Grant Program staff the right to discuss
my case in that same forum. I understand that filing an appeal will not negatively impact my right to apply for future benefits through this
Program and will not be held against any future applications that I make.
Parent/Guardian Signature ____________________________________________ Date ______________
Applications submitted without both signatures will be returned as incomplete. These statements must be read, signed and dated.
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SUBMIT ALL APPLICATIONS TO: HO-CHUNK NATION K-12 PROGRAM P.O. BOX 667 BLACK RIVER FALLS, WI 54615
PHONE: (715) 284-4915 OR (800) 362-4476 FAX: (715) 284-1760 EMAIL: SCR@HO-CHUNK.COM
