STUDENT ENROLLMENT APPLICATION FOR STUDENTS ENROLLED IN BUREAU-FUNDED SCHOOLS

BIA FORM 6248 OMB NO. 1076.122 EXPIRES 12/31/93 JANUARY 1988

NAME OF SCHOOL ______

DAY SCHOOL ( ) BOARDING SCHOOL ( )

1. Identification Social Security #: ______

Name of Student: ______Last First Middle

Address: P.O. Box ______Street ______

City: ______State ______Zip Code: ______

Miles from home to school: ______

Date of Birth: ______Verified by: ______Month Day Year

Place of Birth: ______Sex: Male ( ) Female ( )

Tribal Affiliation: ______Degree Indian: ______

Enrollment Number: ______Home Agency: ______

Religious Affiliation (Optional): ______Father: ______

Address: ______Mother: ______Address: ______Tribal Affiliation: ______Home Agency: ______Tribal Affiliation: ______Enrollment Number: ______Home Agency: ______Living: ( ) Deceased: ( ) Enrollment Number: ______Occupation: (Optional) ______Living: ( ) Deceased: ( ) Employer: ______Occupation: (Optional) ______Telephone: Home ______Employer: ______Work ______Telephone: Home ______Emergency Name & Phone: Work ______Emergency Name & Phone: ______Other: (Specify) ______Legal Guardian: ______Other: (Specify) ______Address: ______Other: (i.e. group home, etc): ______

Address: ______Tribal Affiliation: ______

Home Agency: ______Telephone: ______Enrollment Number: ______Student Lives With: ______Occupation: (Optional) ______Telephone: Home______Employer: ______Work ______Emergency Name & Phone:

______