Author: nlumpmouth

Date _______________

Cheyenne and Arapaho Tribes
Johnson O’Malley Program
2022-2023 Application

School Year
2022-2023
Complete One Per Child

Please Mark One Choice
__Returning JOM Student __New Student __CDIB II (C&A Only)
__In Service C&A Tribal Student __Out of Area C&A Tribal Student

PLEASE PRINT
Name___________________________________________________DOB______________
School Attending________________________________School District:________________
Gender: __Male or __Female Grade:______T-Shirt Size: _____Please mark Youth or Adult
Tribal Affiliation: ______________________________Phone________________________
__________________________________________________________________________
Parent/Guardian Name Address City/State/Zip
Parent Signature:_____________________________________________________________
Email Address:______________________________________________________________

Due to the Covid-19 Pandemic. The Cheyenne and Arapaho Tribes Johnson O’Malley Program will not deliver school supplies or backpacks this year to your community.
The Cheyenne and Arapaho Tribes is providing school supply, backpack, and PPE supply assistance for your child or children.
All JOM students will need to complete an application, and provide a legible copy of the child’s Membership or Enrollment Card. All students must have their own membership or enrollment card this year for all JOM services. For students who are not enrolled with a Federally Recognized Tribe parent must show proof that the child is 1/4 or more Indian, by showing proof of parent Indian blood, and a copy of the child’s birth certificate to show relationship to parent.
Cheyenne and Arapaho Tribal Out of Area students must submit application and Membership or Enrollment card. CDIB II Students must provide a copy of the child’s CDIB II
document from the Tribal Enrollment Office.
These services are based on availability of funds.

Please submit application to: Johnson O’Malley Program
PO BOX 167
CONCHO OK 73022
OR EMAIL APPLICATION TO:
fwilliams@cheyenneandarapaho-nsn.gov
DO NOT WRITE BELOW THIS
PLEASE CALL: APPROVED AMOUNT:_______
405-422-7639 OR APPROVED BY:___________
405-422-7566