Form no. 04929 EDU-EC Rev. 4/2017
Application for Services
A COPY OF THE FOLLOWING DOCUMENTATION SHOULD BE PROVIDED TO DETERMINE
ELIGIBILITY AND FOR APPLICATION TO BE CONSIDERED FOR SERVICES:
Copy of birth certificate
1. Child’s information:
_____________________________________________________________________________________________
First Middle Last Suffix
2. Gender: 3. Age: 4. Birth date: 5. Social Security number:
Male
______________
/ /_________
_____________________
6. Address: 7. Phone number(s):
Mailing address: _______________________________________________
Physical address: ______________________________________________
City: ____________________________________ State: ______________
ZIP: ____________ County: _______________________
Work: (_____) ____________
Home: (_____) ____________
School: (_____) ____________
8. Parent/guardian information:
Name: _______________________________________________________________________________________
First Middle Last Suffix
Birth date: / /_______
Email address: ________________________________________________
Please check services your child requests:
Chickasaw language flashcards Health and education brochures
Chickasaw Reading Program School Readiness Curriculum Program* (requires verification of no Head Start program and/or the
child is not enrolled in public school program)
Determination of eligibility is based upon a completed and signed application with the required documentation.
I certify that the information I have submitted is true to the best of my knowledge and realize it is subject to verification;
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.
________________________________________ ______________________
Signature of parent/guardian Date
Contact Information:
Lacey McFadden, resource monitor and special projects manager – (580) 421-7711 / Lacey.McFadden@chickasaw.net
The Chickasaw Nation Early Childhood Division 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.
Governor
Chickasaw Nation
Early Childhood Division
Child Care and Early Childhood Programs
300 Rosedale Road / Ada, OK 74820 / (580) 421-7711 / Fax (580) 436-0128
