STUDENT ENROLLMENT APPLICATION
FOR STUDENTS ENROLLED IN BUREAU-FUNDED SCHOOLS
BIA FORM 6248
1076-122
JANUARY 1988
OMB NO.
EXPIRES 12/31/93
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: _____________________________
Mother: _____________________________
Address: ____________________________
Address: ____________________________
______________________________
______________________________
Tribal Affiliation: _____________________
Tribal Affiliation: _____________________
Home Agency: _______________________
Home Agency: _______________________
Enrollment Number: __________________
Enrollment Number: __________________
Living: (
Living: (
)
Deceased: (
)
)
Deceased: (
)
Occupation: (Optional) ________________
Occupation: (Optional) ________________
Employer: ___________________________
Employer: ___________________________
Telephone: Home _____________________
Telephone: Home _____________________
Work _____________________
Work _____________________
Emergency Name & Phone:
Emergency Name & Phone:
______________________________
______________________________
______________________________
______________________________
Other: (Specify) ______________________
Other: (Specify) ______________________
Legal Guardian: ______________________
Other: (i.e. group home, etc): ____________
Address: ____________________________
Address: ____________________________
Tribal Affiliation: _____________________
Telephone: __________________________
Home Agency: _______________________
Student Lives With: ___________________
Enrollment Number: __________________
Telephone: Home_____________________
Occupation: (Optional) ________________
Work ____________________
Employer: __________________________
Emergency Name & Phone:
____________________________________