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Ralph Perdue Center
WOMEN & CHILDREN CENTER INNER HEALING
988
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Johnson O’Malley Program Application
"
*
" indicates required fields
STUDENT INFORMATION
Student Name
*
Date of Birth
*
MM slash DD slash YYYY
Phone Number
*
School
*
Grade
*
Does student have an IEP?
*
Yes
No
Parent or Guardian's Name
*
Parent or Guardian's Email
*
Parent or Guardian's Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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Iowa
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New York
North Carolina
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Northern Mariana Islands
Ohio
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Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
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Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Consent
*
I agree.
I, as the parent or legal guardian, of the above-mentioned student do hereby authorize FNSBSD to release any and all information regarding my student’s file as it relates to the eligibility/application for assistance from Fairbanks Native Association.
This authorization includes access to the above-mentioned student’s PowerSchool records including but not limited to the following items listed here:
-School Registration/Attendance
-Grade Reports
-Transcripts
-Graduation Progress
-Current Individualized Educational Plan (IEP) and Related Progress Reports
-Directory Information
-Demographic Information
The information listed above is permitted to be released to Fairbanks Native Association Johnson O’Malley Program.
TRIBAL ENROLLMENT VERIFICATION FORM
Name of Applicant
*
Tribal Affiliation
*
Date of Birth
*
MM slash DD slash YYYY
Roll Number, if known:
Submit copy of Tribal Identification Card, if available.
Accepted file types: jpg, png, bmp, pdf, doc, pages, docx, Max. file size: 2 GB.