OMB Control No: 1810-0021 (Exp. 04/30/2023)
ED 506 FORM
INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM FOR TITLE VI INDIAN EDUCATION FORMULA GRANT PROGRAM
Andes Central School District 11-1
1001 High St., Lake Andes, SD 57356
Parent/Guardian: This form serves as the official recoord of the eligibility determination for each individual child included in the student count for the Title VI Indian Education Formula Grant Program. If you choose to submit a form, your child could be counted for funding under the program. The grantee receives the grant funds based on the number of eligible forms counted furing the established count period. You are not required to complete or submit this form unless you wish for your child(ren) to be included in the Indian student count. This form should be kept on file with the grant application and will not need to be completed each year. Where applicable, the information contained in this form may be released with your prior written consent of an eligible student (aged 18 or over), or if otherwise authorize by law, if doing so would be perissible under the Family Educational Rights and Privacy Act, 20 U.S.C. 1232g, and any applicable state or local confidentiality requirements.
Additionally, this form will serve the purpose of certifying your childs's JOM eligibility.