Tunica-Biloxi Tribe Of Louisiana-Non Trio-UB-Student Application

Tunica-Biloxi Tribe of Louisiana

EDUCATION DEPARTMENT

Student Application

Tunica-Biloxi Parent & Student:

We are excited to roll out our new U. S. Department of Education grant, the Indian Children & Youth Program: Accessing Choices in Education (ACE), to enhance our existing education efforts. This ACE Grant funds educational services to Tunica-Biloxi students (grades K-12) no matter where they live. This resource is not just for students who may be struggling in school, but also for students who want to excel and get ready for college, career selection, or military service.

The first step toward providing services for your student will be to complete the Student Application and Authorization & Release forms; please complete all sections and upload a copy of your most recent report card/transcript with this application. The Student Application and Authorization and Release Forms must be signed by both student and parent.

Student Information
Tribal Roll Number
Name*

First NameMILast Name
Gender*

MaleFemale
DOB*

MonthDayYear
mm-dd-yyyy
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County / Parish*
Student Email Address*
example@example.com
Student Best Contact #
(999)999-9999
Student Best Contact Time
Parent/Guardian Name*

First NameLast Name
Relationship to Student*
Parent Email Address
example@example.com
Parent Cell/Best Contact #
(999)999-9999
Parent Best Contact Time

School Information
Current Grade Level*
Current School*
School Location*
School ID #
High School Students (Grades 9-12 only):
Diploma Plan

Test Scores

	Score	Test Date
ACT Composite
SAT
PSAT

Expected High School Graduation
Overall Grade Point Average
GPA Scale

4-point scale weighted4-point scale unweightedOther

Goals / Interests
Educational Goal*

Graduate / Professional Degree4-Year Program / Post-Secondary Degree2-Year Program / Post-Secondary DegreeVocational-Technical Program / CertificateMilitaryWorkforceUndecided

Career Interests

	Career Name
1
2
3

Hobbies / Extra-Curricular Activities

	Activity Name
1
2
3

Which Educational Supports are of Interest? (select all that apply)*

Academic Skills CoachingAcademic Tutoring / Test PrepAcademic Counseling and MentoringCollege /Career PrepLife / Social Skills TrainingSpecial Education / Disability ResourcesCultural Enrichment / STEAM Enrichment / Tunica Language

Student Application Authorization
Student Application AUTHORIZATION

I hereby grant permission for my son/daughter, _{main_name}_ (STUDENT NAME), if accepted, to participate in the Tunica-Biloxi Education Department (TBED). I also give my consent to _{current_school}_ (SCHOOL ATTENDING), to make any and all information pertaining to my child’s educational progress in school available to TBED staff. As a parent, I will fully support the goals of TBED and the support they provide to help my child attain these goals. I give the school my authorization to release the aforementioned information to TBED staff. As a participant, I understand that in order to receive resources and educational services, I must be registered and an active participant in the TBED. We understand that all information contained in this application is for use only by the TBED and will be kept confidential.
Signature of Applicant*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Authorization and Release Form
Name

First NameMiddle IitialLast Name
Current School
Student ID#
Location
ACADEMIC RECORDS RELEASE STATEMENT

The person or persons signing below give the Tunica-Biloxi Education Department (TBED) consent to request and receive the minor student's academic records, including high school enrollment, academic progress report, high school transcript, state test scores, SAT or ACT exam scores, high school graduation verification, and attendance/behavior reports, FAFSA completion, college applications and proof of college enrollment. Records are kept private in accordance with federal law will be used to determine program eligibility and academic progress.

Medical Release

In the event of an emergency illness, injury, or accident, the person or persons signing below authorize the Tunica-Biloxi Education Department (TBED) to take all necessary steps to provide first aid and medical treatment to my son/daughter/ward. This includes an authorization for transportation to a hospital or medical facilities, including outside of the Tunica-Biloxi Tribe of Louisiana offices, to administer necessary medical care. I/we authorize the release of medical and treatment information to the Tunica-Biloxi Education Department personnel only for the limited purpose of assisting to admit students for emergency care, assisting to release students from emergency medical care, and obtaining the medical bill associated with the emergency care. I/we further agree to use my son’s/daughter’s/ward's insurance coverage before using TBED’s medical coverage in paying medical bills that may be incurred. I/we understand that the balance not covered by insurance will be my/our responsibility to pay. I/ we agree to release TBED from all legal claims and from any liability except those claims and rights that arise from gross negligence or willful misconduct on the part of the Tunica-Biloxi Education Department personnel. I/we have read the above information and agree to allow {name} to participate in the Tunica-Biloxi Education Department as well as in all excursions taking place as of this date, based on the conditions indicated above.

Media Release

The person or persons signing below permit the Tunica-Biloxi Education Department representative and/or the news media to photograph, videotape, audiotape, duplicate and transfer to any present or future agents. The Tunica-Biloxi Education Department and the news media may use the photographs, videotapes, and audiotapes only as appropriate to promote the Tunica-Biloxi Education Department, related college enrollment objectives, and program activities. No compensation will be paid for this use.

Authorization:

We hereby certify that the information reported in this authorization and release form is true, complete, and accurate to the best of our knowledge. We understand that a false statement or misrepresentation will make the applicant ineligible to participate with the Tunica-Biloxi Education Department.
Parent/Legal Guardian's Name

First NameLast Name
Parent/Legal Guardian's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Student's Name

First NameLast Name
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

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