Parent/Guardian Signature _______________________________________________ Date _________
Parent/Guardian Signature ____________________________________________ Date __________
additional sheets may be attached if needed
Address
City, State, Zip
City, State, Zip
Name
Vendor Payment and Reimbursement Information
Name
Address
Applications submitted without both signatures will be returned as incomplete. These statements must be read, signed and dated.
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 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 state 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.
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(rens) 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
Pre K-12 Educational Grant Program 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. 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.
Certification Statement and Information Release
Program Compliance and Appeal Acknowledgement
SUBMIT ALL APPLICATIONS TO: HO-CHUNK NATION PRE K-12 PROGRAM PO BOX 667 BLACK RIVER FALLS, WI 54615
updated 3/2010 Telephone: 715-284-4915 or (800)362-4476 Fax: 715-284-1760
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signature
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