Johnson-O'Malley (JOM) Native Student Activities Grant Program

Email
example@example.com
Johnson O’Malley (JOM) Native Student Activities Program

The CITC-JOM Native Student Activities Program provides assistance to meet the educational needs of Alaska Native and American Indian students enrolled full-time in Preschool - 12th grade in the Anchorage School District (ASD).
Today's Date

MonthDayYear
Date
Amount Requested ($250 maximum per student from August through July)*
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Student Gender*
School Where Enrolled / Attending:*
Grade Level*
Parent / Guardian Name*

First NameLast Name
Student Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Please enter a valid phone number.
Parent / Guardian Email (if available)
example@example.com
Statement of Purpose
What types of assistance does your student need? (select up to 2 options)*

CalculatorCap and GownField/School TripGym ClothesInstrument/MusiciPadLaptop/ComputerSchool clothes/winter gearSchool FeesSports GearSchool SuppliesTutoring
How will it help your student's educational goals?*
May we contact you at the end of the school year to discuss how this grant helped you achieve your goals?

YesNo
Attach student’s Certificate of Indian Blood or Tribal Enrolment (if unavailable, you can include Parent’s CIB/tribal enrollment and student’s birth certificate; unfortunately we cannot accept Native Corporation cards)

If your using your phone, you can take a picture and attach it here.
Cancelof
Required signatures:
By signing this application, I confirm that I will use Johnson O'Malley Funds for the intended purpose(s) specified above to provide for my student’s educational needs.
Parent / Guardian / Adult Youth (18 years or older) Signature*

Clear
Should be Empty:

Johnson O’Malley (JOM) Native Student Activities Program

Statement of Purpose

Required signatures: