Fillable Youth Services Clothing Grant (The Chickasaw Nation)

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Youth Services Clothing Grant (The Chickasaw Nation)

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Form no. 04791 CS-YS Rev. 6/2020
Youth Services Clothing Grant
Return applications by mail or in person to:
The Chickasaw Nation Youth Services Division
231 Seabrook Road / Ada, Oklahoma 74820
The Chickasaw Nation Youth Services Division and the applicant agree to strictly maintain the confidentiality of all information. Applicants 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.
Household Information
Current mailing address:
City, State, ZIP:
Physical address:
City, State, ZIP:
Phone number:
Email address:
School Information
Report cards or progress reports are required for K-12
th
grade.
The most recent progress report/report card will be sufficient for grade documentation.
**Application is considered incomplete if grades are not attached. **
School district:
City, State, ZIP:
Student Information – Please list All Chickasaw students in household
Full name (first, middle, last, suffix)
Birth date
Age
School name
Grade
Homeschool
Y/N
Parent Signature
Birth date: ________________ (required for security purposes)
Authorized user: ___________________________________
Optional (this can be any person you would like to have access to your account)
Password or PIN no.: _____________ *authorized person will need password/PIN no. to access account for release of information or to activate card
Date: _________________
Is the signature above the custodial parent/legal guardian of student? Yes No
*****If not the custodial parent/legal guardian of student, you must attach current documentation that the student is legally in your care*****
****COMPLETED Applications must be postmarked or received by February 15
th
****
Youth Services Division
231 Seabrook Road / Ada, OK 74820 / (580) 272-5585
Bill Anoatubby
Governor
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Youth Services Clothing Grant (The Chickasaw Nation)

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Completed 31 January 2021

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