School Supplies & Uniform Application

School Year 2015-2016
Native American Student Services
Oklahoma City Public Schools
900 N Klein Rm 428
Oklahoma City, OK 73106
Phone: 405.587.0355
Fax: 405.297.6642
School Supplies & Uniform Application
Deadline: June 19, 2015
Student’s Name: ___________________________________ Student’s Tribe(s): ________________________________
School: _____________________________________________________ ID #:________________ Grade: _________
Parent/Guardian Name: ____________________________________________ Phone: __________________________
Address: ___________________________________________ State, City, Zip: _______________________________
Email Address:______________________________________ Emergency Phone & Name: ______________________
Please mark what you are applying for:
School Supplies
School Uniform Voucher
*School uniform vouchers will be for $30/student. Limited # of uniform vouchers will be available.
Total Number in Household: ________
Monthly Income of Entire Household: _________________
(Income Is Subject To Verification)
My child receives:
Free _____
Reduced _____ Breakfast or Lunch
(To be verified with the child nutrition services)
If your gross household income exceeds the amount indicated on the scale on the back of this form and you wish to apply
under any special hardship conditions or unusual circumstances, describe below the nature of the hardship and submit
documentation or proof of circumstance. You may use additional sheets to this application as needed.
_________________________________________________________________________________________________
I hereby certify that all of the above information is true and correct to the best of my knowledge. I give my permission to
verify my child’s free or reduced lunch status with child nutrition services. I understand that I must qualify for the free or
reduce lunch program in order to receive school supplies or a uniform voucher from JOM. I understand that I must apply
each school year for these services.
____________________________________________
Parent/Guardian Signature
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__________________________
Date
School Supplies can be picked up at the NASS office between 8:30am – 4pm on July 27-31, 2015
School Uniform vouchers may be picked up at the same time as school supplies. However, please note that only
a limited number of vouchers will be available due to funding. Therefore, not every child who applies will receive a
uniform voucher
JOM will try to give every student who applies a for school supplies a school supply kit.
Deadline: June 19, 2015