OMB Number:  1810-0021
Expiration Date:  00/00/0000

U. S. DEPARTMENT OF EDUCATION
OFFICE OF INDIAN EDUCATION
WASHINGTON, DC  20202
TITLE VII STUDENT ELIGIBILITY CERTIFICATION
Elementary and Secondary Education Act, Title VII, Part A, Subpart 1

Parents:  Please return this completed form to  your child's school.  In order to apply for a formula grant under the Indian Education Program, your child's school must determine the number of Indian children enrolled.  Any child who meets the following definition may be counted for this purpose.  You are not required to complete or submit this form to the school.  However, if you choose not to submit a form, the school cannot count your child for funding under the program.  This form will become part of your child's school record and will not need to be completed every year.  This form will be maintained at the school and information on the form will not be released without your written approval.

Definition:  Indian means any individual who is (1) a member ( as defined by the Indian tribe or band) of an Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized by the State in which the tribe or band reside; or (2) a descendant in the first or second degree ( parent or grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.

PARENT/GUARDIAN: fill in the areas below marked with an (X), as the minimum requirements.  This form must be kept on file in the Swartz Creek Indian Education Program Office for student to be eligible.  Miigwech (Thank You).
NAME OF CHILD (X)______________________________ Date of Birth_________
                                             (As shown on school enrollment records)
School Name____________________________________ Grade _____________

NAME OF TRIBE, BAND, OR GROUP (X)___________________________________
Tribe, Band, or Group is:  (Check one)   
                                                                                                              Organized Indian Group
         Federally Recognized,            State                                                 Meeting 5 of the         _____Including Alaska Native    ____Recognized    _____Terminated  _____Definitions Above

Name of Individual with tribal membership:_______________________________________________
Individual named is (Check one):  _____Child      _____Child's Parent     _____Child's Grandparent

Proof of membership, as defines by tribe, band, or group is:
A. Membership or enrollment number (if readily available) _________________________________
B. Other (explain)__________________________________________________________________

Name and address of organization maintaining membership data for the tribe, band, or group:___________________________________________________________________________

I verify that the information provided above is accurate:

PARENT'S SIGNATURE (X)__________________________ DATE (X)_____________

Mailing Address_____________________________________ Telephone________________________