2022-2023 UTTM Student Application

Student Information

Student Name*

Last School Attended*

Current School Enrolled In*

Grade*

Is student enrolled in a federally recognized tribe? *

If yes, what tribe is student enrolled?

Is parent enrolled in a federally enrolled tribe?*

If yes, what tribe is parent enrolled?

Does student have an Individual Education Plan (IEP) with the Special Education Department (SPED) of his/her school? *

Yes

Unsure

Parent/Guardian Information

Parent/Guardian Name*

Email Address*

Home Phone*

Cell Phone*

Preferred Method of Communication*

Phone Call

Text

Mailing Address*

Physical Home Address*

In case of an emergency and we are unable to reach you, please provide two emergency contacts

Emergency Contact #1*

Emergency Contact #1 Relationship*

Emergency Contact #1 Phone Number*

Emergency Contact #2*

Emergency #2 Relationship*

Emergency #2 Phone Number*

Consent for Release of Information

The purpose for the Consent for Release of Information is to provide and assure quality educational services for Native American students who participate in the Ute Indian Tribe Tutor/Mentor Program.

I give my consent to release the following information:

- Academic Progress (Power School System, Student Information System, Online Learning Platforms, Etc.)

- State and National Testing Results

- Attendance

I give my permission for my child to participate in the Ute Indian Tribe Tutor/Mentor Program.

I give my permission to the Ute Indian Tribe Education Department to take and use photographs and/or digital images of my children and me for use in news releases, social media, and/or educational materials.

I understand the information regarding my child is confidential and may not be given to any person or agency without my written permission. I understand that I can withdraw my consent for my child at any time by notifying the UTTM Program Coordinator at (435) 722-2331.

Yes

By typing my name in the electronic field below, I am confirming that I have read, understand, and agree to the above information. *

If you'd like your student to be in the UTTM Program for the 2022-2023 school year, please submit the application below.

If you'd like your student to be in the UTTM Program for the 2022-2023 school year, please submit the application below.

2022-2023 UTTM Student Application

Student Information

Parent/Guardian Information

In case of an emergency and we are unable to reach you, please provide two emergency contacts

Consent for Release of Information

Tutor/Mentor Services

Track

Support

Tutor

Tutor/Mentor Program Coordinator

Contact the Tutor/Mentor Program Coordinator

Uintah River High School

Ute Indian Tribe Education Department

Ute Tribe

Hours

Choose website:

If you'd like your student to be in the UTTM Program for the 2022-2023 school year, please submit the application below.

If you'd like your student to be in the UTTM Program for the 2022-2023 school year, please submit the application below.

2022-2023 UTTM Student Application

Student Information

Parent/Guardian Information

In case of an emergency and we are unable to reach you, please provide two emergency contacts

Consent for Release of Information

Tutor/Mentor Services

Track

Support

Tutor

Tutor/Mentor Program Coordinator

Contact the Tutor/Mentor Program Coordinator

Uintah River High School

Ute Indian Tribe Education Department

Ute Tribe

Hours