* Required

Title VI ED 506 Indian Student Eligibility Certification Form

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Education Rights and Privacy Act, 20 U.S.C. 1232g, and any applicable state or local confidentiality requirements.

Student Information

Child's Namerequired

Child's Date of Birthrequired (mm/dd/yyyy)

Child's Graderequired

Child's Schoolrequired

Tribal Membership

Name of individual with Tribal membershiprequired

The individual with Tribal membership is the*

Child Child's Parent Child's Grandparent

Name of Tribe or Band individual is a member ofrequired

The Tribe or Band is:*

Federally Recognized State Recognized Terminated Tribe (Documentation Required) Member of an organized Indian group that received a grand under the Indian Education Act of 1988 as it was in effect October 19, 1994. (Documentation Required)

Proof of Membership: Membership may be established by including an enrollment number if available or by other evidence as appropriate

Enrollment Number

Other Proof of Membership

Please Describe and attach any supporting documents

Supporting Documents

Max file size: 10 MB

Name of Organization maintaining membership datarequired

Address of Organization maintaining membership datarequired

Parent/Guardian Attestation Statement

By entering my name and today's date below, I verify that all the information provided above is accurate.

Namerequired

Today's Daterequired

Addressrequired

Email Addressrequired

This form is a digital version of US Department of Education ED 506 Form with OMB Number: 1810-0021 Expiration Date: 02/29/2020

If you would prefer to complete a paper copy of this form, please click here to download. Paper forms may be scanned and Faxed to 503-356-3760, or mailed to:

ATTN: Title VI AI/AN Program

Multilingual Department

1260 NW Waterhouse Ave

Beaverton, OR 97006

Please send a confirmation email to the address below: