Fillable Petition for Re-Admission (The Chickasaw Nation)

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Petition for Re-Admission (The Chickasaw Nation)

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Page 1 of 3 Form no. 04676P EDU Rev. 3/2017
Petition for Re-Admission
Contact Information:
Full legal name (first, middle initial, last, suffix):
Home phone:
Address:
Cell phone:
City, state, ZIP:
Email address:
Ethnicity:
Asian Black Hispanic Native American
White Other: __________________________
Tribal affiliation (if Native American):
Please explain below why you should be re-admitted to the Adult Learning Program:
_
Certification – I certify that the information provided on this form is true and correct.
Signature:
×
Date:
Guardian’s signature (if under 18):
×
Date:
The Chickasaw Nation Supportive Programs and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments thereto. The parties
agree that the information contained in said application shall be considered “Confidential Information” and shall not be disclosed to third persons, except upon written consent of the
applicant or as otherwise required by law.
Bill Anoatubby
Governor
Education Division
Adult Learning Program – DOUGLAS H. JOHNSTON BUILDING
300 Rosedale Road / Ada, OK 74820 / Phone: (580) 421-7711 / Fax: (580) 272-1224
Page 2 of 3 Form no. 04676P EDU Rev. 3/2017
Intake Interview Notes: (This Page for Office Use Only)
Criminal History – Client checked Yes No that they have been convicted of a felony or misdemeanor.
Are you on supervised or unsupervised probation? Supervised Unsupervised
Do you have any pending criminal charges against you? Yes No
(If yes, brief description of conviction):
Student is a referral to our program? Yes No Referral document on file? Yes No
If yes, name of referring person:
Referring agency:
Address:
City, state, zip code:
Contact phone no.:
Special Services Required (Intake notes):
Other Intake Notes:
Application packet is complete? Yes No
Intake specialist signature: Date of intake:
The Chickasaw Nation Supportive Programs and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments thereto. The
parties agree that the information contained in said application shall be considered “Confidential Information” and shall not be disclosed to third persons, except upon written consent
of the applicant or as otherwise required by law.
Page 3 of 3 Form no. 04676P EDU Rev. 3/2017
(FOR OFFICE USE ONLY)
Date petition received:
Re-admission allowed Re-admission denied
Explanation of recommendation:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Education Division Committee – Approved by:
Committee Member Signature
Title
Date Reviewed
The Chickasaw Nation Office of Supportive Programs and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments
thereto. The parties agree that the information contained in said application shall be considered “Confidential Information” and shall not be disclosed to third persons, except upon
written consent of the applicant or as otherwise required by law.
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Petition for Re-Admission (The Chickasaw Nation)

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Completed 31 January 2021

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