Form no. 04245EHS CS-YS 9/2020
High School Senior Expense and Honor Cord
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Section I. Applicant Information: Date:
(Please type or print clearly)
Student Name:
First Middle Last Suffix
Mailing address:
Street City State ZIP
Physical address:
Same as mailing Street City State ZIP
Birth date: Home phone: ( ) Cell phone: ( )
Parent or legal guardian name:
First Middle Last Suffix
Birth date: Home phone: ( ) Email address:
(Required for security purposes)
Section II. Senior Request:
Must include documentation, flyer, brochure or receipts outlining the senior cost and activity requested for funding
Please check all that apply:
Senior expenses – list expenses:
See brochure for allowable expenses – announcements/cap and gown, class ring, letterman jackets, senior pictures, etc. Available once
per lifetime during senior year.
Honor cord: signifies you are a graduating senior of the Chickasaw Nation
Application must be received by March 30
th
to ensure processing time. Available once per lifetime during senior year.
Section III. Senior Verification:
(Section must be completed by counselor or school administration)
By signing below you are verifying the above student is a high school senior and in good standing to graduate:
Signature and title of counselor or school administration Date
Phone: ( ) Email address:
Section IV. School Information:
School name: School district:
Expected graduation date:
The most recent report card or progress report is required, including homeschooled students.
Student shall be entering 12
th
grade or a senior in high school to apply
*Last report card or previous school year is sufficient if applying July-September* *after September need most recent report card*
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Application will be completed in its entirety and be accompanied by a receipt of purchase or other
documentation detailing what the cost is to participate in stated activity, organization, club, etc. The student’s
most recent grade report is also required for processing of the application. Incomplete applications will
not be processed.*NOTE: Submission of this application is not a guarantee of funding. Program guidelines
