Title VI ED 506 Indian Student Eligibility Certification Form

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This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need t o be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or older), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. 1232g, and any applicable state of local confidentially requirements.

NOTE: IF MORE THAN ONE CHILD, PLEASE FILL OUT SEPERATE FORMS.
NOTE: IF YOU HAVE FILLED THIS FORM OUT FOR YOUR CHILD IN PREVIOUS YEARS, DO NOT FILL OUT AGAIN
NOTE: ONLY FILL THIS FORM OUT IF YOUR CHILD HAS A CIB (CERTIFICATE OF INDIAN BLOOD)

STUDENT INFOMATION *

Name of Child

Date of Birth *

YYYY

Grade level (this coming year) *

Name of school *

TRIBAL ENROLLMENT *

Name of individual with tribal enrollment (Individual named must be a descendent in the first or second generation)

The individual with tribal membership is the? *

Child

Child's Parent

Child's Grandparent

Name of Tribe or Band for which individual above claims membership? *

The Tribe of Band is (select only one) *

Federally Recognized

State Recognized

Terminated Tribe (please mail documentation to Magdalena Schools)

Member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994 (please mail documentation to Magdalena Schools)

Proof of enrollment in Tribe or Band listed above, as defined by Tribe or Band is *

If you have a CIB, please check the CIB box and put the CIB number in the box labeled "other"

CIB

Other evidence of membership in the tribe listed above (Please mail documentation to Magdalena Schools)

Other:

Required

Name and address of tribe or band maintaining enrollment data for the individual listed above *

Attestation Statement *

I verify that the information provided above is accurate. Signature and address of the Parent/Guardian is needed (please type your name, address, and today's date below)

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