Page 1 of 2 Form no. 04924 CS-EDU Rev. 3/2017
the
Chickasaw Nation
Education Division
Vocational Rehabilitation
300 Rosedale Road / Ada, OK 74820 / (580) 436-0553 / Fax (580) 436-0830 / TDD (580) 310-9634
Special Needs Assistance for
Chickasaw Citizens with Disabilities
By completing this application, the Chickasaw citizen whose signature appears below makes application for the
Special Needs Assistance for Chickasaw Citizens with Disabilities program provided by the Chickasaw Nation.
The program is available to Chickasaw citizens with a documented mental or physical disability. All other
available resources must be applied for and used prior to applying for this program. The program provides up to
$500 per year on a reimbursement basis for fees incurred to participate in recreational activities such as
Special Olympics or other recreational activities they choose. For the purposes of this program, social
networking online is not considered a recreational activity. Applicable expenses include disability-related
assistive technology needed for the Chickasaw citizen with a disability to be able to participate in a recreational
activity or expenses incurred to participate in a recreational activity. Due to limited funding, the program shall
not help with computers, laptops or iPads. The Chickasaw citizen or his/her parent/legal guardian shall be
responsible for mailing the completed application and required documents to the Chickasaw Nation Vocational
Rehabilitation. Along with the completed application, the Chickasaw citizen or parent/legal guardian
must submit a copy of the Chickasaw citizen’s Chickasaw Nation certificate or citizenship card, a copy
of the Chickasaw citizen’s current Individualized Educational Plan (IEP) or documentation of disability
from a physician, and receipts for assistive technology or expenses paid to participate in the
recreational activities.
(Please type or print clearly in ink)
Name of Chickasaw citizen (first, middle initial, last):
Name of school or physician verifying disability:
Parent/legal guardian’s name (if applicable) (first, middle initial,
last):
School or physician contact (if applicable):
Chickasaw citizen’s address – street, city, state and ZIP:
Address of school or physician:
Chickasaw citizen’s phone:
School or physician’s phone:
Chickasaw citizen’s email:
School or physician’s email:
What is your disability and how does it impact your ability to participate in recreational activities?
NOTE: all other resources available must be applied for and used prior to applying for this program. Applicant should have
applied for the donation/sponsorship program offered by the Chickasaw Nation Youth Services Division prior to making this
application.
What other resources have you applied for to participate in this recreational activity? Please provide proof of approval or
denial from all other resources available to you:
