Citizen Potawatomi Nation
Admissions Document
JOM Application Checklist: CPN E&T Program services are made possible thru federal grants and documentation is required. You will need to provide AT LEAST the following verifications or documentation*. ITEMS 1-7: Provide ONE document from each. ITEM 8: Provide ANY and ALL verification for past 6 months Income.
1. Identification
□Birth Certificate
□Driver’s License □State Issued Picture I.D.
2. Proof of Residence (includes STUDENT OR PARENT’s name, address, & dated last 30 days)
□Utility Bill □Postmarked envelope □Rent Receipt □Notarized Statement signed by person who owns the house where you are currently living 3. Native American Indian Blood and/or Tribal Enrollment
□Tribal Enrollment Card
□BIA Letter
□CDIB (Certified Degree of Indian Blood)
4. Social Security Number Card. OR Lost card receipt from Social Security Office filing for a replacement card. 6.
ALL applicants must provide ONE of the following:
□ Proof of enrollment in Educational Facility 7. ALL INCOME SOURCES FOR THE LAST 6 MONTHS MUST BE PROVIDED for EVERYONE in your household. Examples of this type of documentation include:
□Pay stubs or Letter from employer □Social Security Benefit letter □DHS Food Stamps or TANF Printout □Gas/ Oil/Land Lease papers □Unemployment Benefit letter □Federal Financial Aid/Grant papers (PELL and/or Tribal) 8.
□ Any Tribal Assistance □Retirement Benefit letter □ Child Support document □Notarized statement of support □Alimony papers □OESC Wage History Summary
Completed JOM Survey:
□ Survey rates your opinion on services which should be provided. A summary of all parents opinions are used to determine how JOM Program will focus activities and efforts during academic year.
9. GRADES, TRANSCRIPT or Assessment Test (Taken at CPN) OR provide test results from test taken within the last year.
□Grades □Transcript
□ ITBS
□IEP
□ ACT/SAT
□ CAPS/COPS/COPES
Your household is defined as anyone who was included on the same income tax document as you were. If claiming ZERO income from any source, you must explain how you have provided for yourself (home, utilities, food, etc.) *Additional documents may be requested depending on your particular household situation. Review and approval process may take as long as 7 to 14 business days. You can expedite the process by providing complete information and documentation. The sooner you complete the documentation process, take the assessment test, the sooner determination of eligibility and counselor assignment can occur. Page 1 of 12
Citizen Potawatomi Nation
Admissions Document
EDUCATION APPLICATION CHECKLIST Date Received: *THIS PAGE FOR ADMISSIONS STAFF USE ONLY* NAME: ELIGIBILITY VERIFICATION RECORD
YES
NO
N/A
COMMENTS
1. BIRTH CERTIFICATE OR DRIVER’S LICENSE 2. Proof of RESIDENCE - BILL/LETTER (POSTMARKED OR DATED WITHIN LAST 30 days) 3. TRIBAL ENROLLMENT or C.D.I.B. CARD 4. SOCIAL SECURITY CARD 5. INCOME VERIFICATION FOR LAST 6 MONTHS 6. PROOF OF SCHOOL ENROLLMENT -For JOM Education Applicants – See Below Additional Items Required 7. JOM Survey 8. GRADES OR TRANSCRIPT (PREVIOUS SEMESTER or GRADING PERIOD PREFERRED) Other acceptable documents include SCHOOL TRANSCRIPT OR THE ADULT BASIC EDUCATION TEST (TABE) OR ACT SCORE OR CAPS/COPS/COPES (ANY CAREER ASSESSMENT or PLACEMENT TEST Scores)
VERIFIER’S NAME
DATE
Admissions Notes:
APPLICATION STATUS THIS APPLICANT
{
} IS
{
} IS NOT
HEREBY APPROVED
_______________________________ DIRECTOR
_______________ DATE
COMMENTS
Page 2 of 12
Citizen Potawatomi Nation
Admissions Document
DATE OF APPLICATION:
DATE APPLICATION RECEIVED:
SOCIAL SECURITY #
GENDER
□ Male
BIRTH DATE
AGE
□ Female
___________________________________________________________________________________________________ NAME: LAST FIRST MIDDLE INITIAL MAIDEN COUNTY
PHYSICAL Residence ADDRESS:
CITY
STATE
ZIP
MAILING ADDRESS if different than Physical
CITY
STATE
ZIP
If P.O. Box or Rural Route is used for mailing address, give directions to your location with major cross streets. EMAIL CONTACT: TRIBAL JURISDICTIONAL AREA(s) PLEASE checkmark the appropriate information. If reside in one of the Oklahoma Counties of: Pottawatomie, Cleveland, Lincoln, Payne, or Oklahoma
□CPN Former Reservation □IOWA Former Reservation
□S&F Former Reservation □KICKAPOO Former Reservation □Cleveland County □ANY OTHER County or State FOR CITY OF SHAWNEE RESIDENTS ONLY: □East of Kickapoo St □West of Kickapoo St PHONE NUMBER(s) Home: In Case of Emergency:
Alternate #:: CONTACT NAME,
RELATIONSHIP,
Other #: ADDRESS:
___________________________________________________________________________________________________ YOUR MARITAL STATUS
□Single
□Married
□Divorced
□Separated □ Widowe
TRIBAL MEMBERSHIP OR AFFILIATION (Identification Required) Federally recognized tribe(s):
U. S. CITIZEN?
□Yes □No
VETERAN / Military Service: (Include Active, Inactive, or Reserves)
SELECTIVE SERVICE REQUIRED IF born after 1959 or between the ages of 18 to 26 years of age
□Yes □No
□Yes □No □Not Applicable
NEPOTISM
Does any member of your immediate family work for the Citizen Potawatomi Nation?
€ NO € Yes - Indicate Name & Relationship. CPN Dept that Relation Works In (if known): EDUCATIONAL LEVEL
□Drop Out
School Name
Last Grade Level Completed
□Student (Pre-K to 12 )
Circle # Years Add’l Education 1
th
2
3
4
5+
□GED □H.S. Diploma □Post H.S. □Certificate □Vo-Tech □Assoc. □BA/BS □Masters □Other: Page 3 of 12
Citizen Potawatomi Nation
Admissions Document
BARRIERS: Checkmark indicates: YES this applies to your situation.
□Lacks Transportation? □Substance Abuse □No Driver’s License □Domestic Violence □ Lack Child Care ? □Current Legal Issues / Warrants? □Have Fines? □ Basic Skills Deficiency □Offender □ Lack Significant Work History? □Felony Offense, - Specify □ School Dropout? □ Pregnant &/or Parenting Youth □Displaced Homemaker Specify □Low Income □Homeless □Single Head? □Single Head of Household w/dependents under 18 □Limited English □ Low Math Skill Level □Disability □Low Reading Skill Level □ Medical Problems? Specify □OTHER Specify: □ Below Grade Level? I AM REQUESTING ASSISTANCE WITH THE FOLLOWING: Checkmark indicates ALL IMMEDIATE NEEDS THAT APPLY.
□ EMPLOYMENT □EDUCATION □SOCIAL SERVICES □ SUPPORTIVE SERVICES □YOUTH SERVICES (JOM etc.) □ OTHER
PLEASE WRITE A SHORT NOTE REGARDING WHAT ASSISTANCE YOU ARE SEEKING:
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CITIZEN POTAWATOMI NATION
ADMISSIONS DOCUMENT
E&T
Household Data: List Names of Household Members, Relationship, Age, and CHECKMARK Priority for Assistance Status if applicable: Name
1.
Tribal Membership (Affiliation)
Relationship to Applicant
AGE
ElderAge 55 & Up
Disabled
Minor Child
Veteran
(APPICANT NAME HERE)
2.
3.
4.
5.
6.
7.
8.
9.
10.
Page 5 of 12
CITIZEN POTAWATOMI NATION
ADMISSIONS DOCUMENT
E&T
Household Income: List All employment for 12-months prior to date of this application for all household members. (Household is defined as family unit as identified for IRS tax purposes.) Name of Household Member
Employer
Start Date (Estimate if Unknown)
End Date (estimate if unknown)
City , State
Gross Pay (before Taxes)
Self:
Spouse:
Other: Other: Other: Other:
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CITIZEN POTAWATOMI NATION
ADMISSIONS DOCUMENT
E&T
List All Other Sources of Income or Financial Support:
SOURCE
Name of household member
Start date (estimate if unknown)
End date (estimate if unknown)
$$ amount per month or payment period
Total
Unemployment DHS/TANF SNAP (food stamps commodities or WIC) Social security Disability retirement or pension Child support / alimony Veteran’s assistance Educational grants Money from relatives
Other (explain) Other (explain)
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CITIZEN POTAWATOMI NATION
ADMISSIONS DOCUMENT
E&T
□Check HERE if NEVER WORKED
EMPLOYMENT HISTORY--
List Current or Most Recent Job First. Include Verifiable Volunteer Work.
1st Employer
Address
Phone #
Supervisor
□Full-Time
□Part-Time
Start – Month/Day/Year
□Volunteer
End - Month/Day/Year
City
State
Zip
Your Position/Job Title
□Temporary or Seasonal Rate of Pay
Average # Hours Per Week
Duties/Responsibilities
REASON FOR LEAVING
2nd Employer
Address
Phone #
Supervisor
City
State
Zip
Your Position/Job Title
□ Full-Time □ Part-Time □ Volunteer □Temporary or Seasonal Start – Month/Day/Year
End – Month/Day/Year
Rate of Pay
Average # Hours Per Week
Duties/Responsibilities
REASON FOR LEAVING
3rd Employer
Address
Phone #
Supervisor
□Full-Time
City
State
Zip
Your Position/Job Title
□ Part-Time □ Volunteer □ Temporary or Seasonal
Start – Month/Day/Year
End – Month/Day/Year
Rate of Pay
Average # Hours Per Week
Duties/Responsibilities
REASON FOR LEAVING
4th Employer
Address
Phone #
Supervisor
□Full-Time
□Part-Time
Start – Month/Day/Year
□Volunteer
End – Month/Day/Year
City
State
Zip
Your Position/Job Title
□ Temporary or Seasonal Rate of Pay
Average # Hours Per Week
Duties/Responsibilities REASON FOR LEAVING Page 8 of 12
CITIZEN POTAWATOMI NATION
(Print Name)
ADMISSIONS DOCUMENT
SS#
E&T
Date:
UNIFORM GRIEVANCE & APPEALS PROCEDURE: The Tribe has established a uniform grievance and appeals procedure applicable to all participants and tribal staff within this 477 program engaged in any type of activity included under the 477 Plan and Employment & Training Program. The procedure insures due process and establishes a series of levels, starting with informal resolution at the staff level. The final level of appeal is to a committee including the Department Director and two other senior level tribal administrative staff. Appeals to final level must be in writing and submitted within ten business days of the action being appealed. Participant will be advised of determination(s) within ten (10) business days of receipt of written complaint(s). The levels are as follows: Step 1: Informal / Verbal Complaint -Resolve informally at staff level. Step 2: Written Complaint: Time and Date received noted, staff relays to Department Director (or Assistant Director). Participant is contacted directly. Director or Assistant Director investigates / reviews complaint. Once determination is made the participant is advised. Step 3: Final Formal Complaint: If unable to resolve or participant is not satisfied with Director’s determination, a written request for Final review may be made by the participant. Department Director will relay all pertinent written documentation to senior level tribal administrative staff that includes one or more of the following as applicable: Human Resource Director, Deputy Administrator, Vice-Chairman, or Tribal Chairman. Step 4: Only when the grievance specifically involves an elected official, will Step 4 apply. All written grievances will be reviewed in accordance with the Tribe’s by-laws. DRUG FREE WORKPLACE / NO FIREARMS ALLOWED: The Citizen Potawatomi Nation maintains a safe and secure drug free workplace and does not allow illegal substances, drug paraphernalia, or firearms upon its property. This policy applies to employees and guests. Anyone found in violation of this policy and/or breaking the law will be subject to appropriate actions including removal from the building or grounds, termination or suspension of services, and appropriate legal procedures. CONFIDENTIALITY: Any information I provide or that is obtained or received on my behalf is considered confidential. I understand all Employment & Training staff is required to maintain confidentiality of participants unless otherwise noted in the release of information to which I agree. RELEASE OF INFORMATION: I certify the information given in this application is correct and true to the best of my knowledge and subject to verification. Falsification of facts is grounds for immediate termination and may result in prosecution under law. I also hereby authorize E&T staff to obtain or release information included in this application and my participant file as it pertains to my eligibility for services, assistance sought on my behalf from other social services programs, for verification of information that I have provided, and/or for reporting purposes. AUTHORIZATION TO RELEASE OR RECEIVE INFORMATION
I certify the information given in this application is correct and true to the best of my knowledge and subject to verification. Falsification of facts is grounds for immediate termination and may result in prosecution under law. I also hereby authorize E&T staff to obtain or release information included in this application and my participant file as it pertains to my eligibility for services, assistance sought on my behalf from other social services programs, for verification of information that I have provided, and/or for reporting purposes. I also authorize my Education Institution to release my grades, transcripts, financial needs summary, account summary, or any other information needed on my behalf to the Employment & Training Department of the Citizen Potawatomi Nation.. INDIVIUALIZED PLAN OF SERVICE: I further understand that a DETERMINATION OF ELIGIBILITY does not guarantee services and that not all services will be financial in nature. I also understand that I am required to complete a formal ASSESSMENT TEST to finalize the application process. I agree to work together with my assigned counselor to develop and prepare an EMPLOYABILITY DEVELOPMENT PLAN which details my individual needs and the steps I will take to achieve my goals. I understand priority is given to those who help themselves and have not previously received services. By my signature below, I indicate my agreement to abide by the policies and procedures set forth, and release of information as necessary to verify information, provide, and/or obtain services on my behalf. Applicant Signature
Print Name
Parent or Legal Guardian Signature IF Applicant is Under 18
Date
Date
Page 9 of 12
CITIZEN POTAWATOMI NATION
ADMISSIONS DOCUMENT
E&T
*THIS PAGE FOR CPN E&T ADMISSIONS STAFF USE ONLY* INCOME CALCULATION
Six (6) Month Period
Total Number In Household:
TO
Excluded Income- Source:
Counted Income ONLY: Applicant
Source
Amount
Other Household Member(s)
Source
Amount
Federal Poverty Guideline Limit:
Total Six Months Income:
Economically Disadvantaged:€ YES Below Federal Guideline
______
€ NO Exceeds Poverty Guidelines *If Youth, At-Risk?
ELIGIBILITY / QUALIFICATION FOR SERVICES
Adults & Youth
□ Working Less Than Full Time □ Under-employed □ Unemployed over 7 consecutive days □ Employed – requires Skill Enhancement □ Individual With Disability □ Homeless □ Household within a Household □ Social Services / Emergency / Disaster
Youth ONLY
□ Leadership Development □ Lacks Employability Skills □ At-risk Youth □ Recertified □ Foster Child □ At-Risk Letter (Over-income 10%)
CHECK ADDITIONAL PAGES REQUIRED
REFFERALS
□ EMPLOYMENT VERFICATION □ FINANCIAL NEEDS SUMMARY □ JOM SURVEY □ JOM PROOF OF SCHOOL ENROLLMENT □ SAFETY PROCEDURES POLICY □ MEDICAL RELEASE IF UNDER 18yrs □ HOLD HARMLESS AGREEMENT □ Notarized RELEASE OF INFORMATION □ OTHER: □ OTHER:
□ Voc-Rehab (IOWA) □ DHS / Food Stamps / TANF □ Women Infant & Children (WIC) □ Domestic Violence/Project Safe □ ICW/Family Preservation □ Behavioral Health / Substance Abuse □ Salvation Army □ Early Head Start / Head Start □ Public / Tribal Housing □ Other:
Page 10 of 12
Citizen Potawatomi Nation
Admissions Document
JOHNSON O’MALLEY NEEDS ASSESSMENT SURVEY ACADEMIC YEAR 2016-2017
A parental survey is a federal requirement of the JOM PROGRAM. The information gathered is needed to determine the educational and culturally relevant needs of the Native American students. The CITIZEN POTAWATOMI NATION JOM provides DIRECT services to the following eight schools: Please place a checkmark next the applicable school □ASHER □EARLSBORO □SOUTH ROCK CREEK □ LITTLE AXE □BETHEL □MACOMB □TECUMSEH □ CHOCTAW □DALE □MAUD □WANETTE □ HARRAH This survey is confidential and anonymous. . Complete one survey per child. You do not have to put your name anywhere on this questionnaire! Please check the category that best describes you. ( ) Parent or Guardian
( ) Student
( ) School Faculty
( ) Other
What do you feel are the main needs of the Native American Students in your public school system? (Please indicate your response by placing a check mark next to any you feel is needed.)
□ Academic Enhancement (tutoring, summer school, special classes). □ Incentive Program (awards, gift certificates, senior costs) □ Educational Support (dues, fees, school supplies / materials, equipment related to school activities or classroom and is needed for student to participate)
□ Native American Awareness by providing cultural events & activities □ Drug & Alcohol Abuse Awareness □ Absenteeism And Drop Out Rates Reduction Activities □ Gang Violence Awareness activities □ Personal Health & Hygiene activities □ Career / Job information □ Special Recognition of Achievement Events □ Other Needs Such As How do you think JOM funds could be used to meet the needs listed above?
Comments or suggestions about the JOM program
Page 11 of 12
Citizen Potawatomi Nation
Admissions Document
Mailing address: Citizen Potawatomi Nation Employment & Training 1601 S Gordon Cooper Drive Shawnee, OK 74873
PH: (405) 598-0797 Or (800) 880-9880 Fax: (405) 598-0833 or 598-0834 Physical Address: 300 East Walnut Tecumseh, OK
Proof of School Enrollment Citizen Potawatomi Nation Johnson O’Malley Program 2016-2017 Must complete and have school official signature (or stamp) to be eligible. Please print clearly or use black/blue ink.
Student’s Name: Address City, State, Zip Social Security#
Birth Date:
Grade Currently Enrolled in
Teacher’s Name:
The following must be completed by school official.
□YES, the student indicated above is enrolled for the School Year 2016-2017 □NO, the student indicated above is NOT enrolled for the School Year 2016-2017. _____ School Name
City ____
School Official Signature
Position / Title
Date
COMPLETED Forms may be faxed to ATTN: E&T ADMISSIONS 405-598-0833. Hand delivered to 300 E. Walnut, Tecumseh, or mailed to the address provided at the top of this form. Page 12 of 12
