Wichozani Spring Program Application : Crazy Horse Memorial®

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APPLICANT INFORMATION
Failure to complete all applicable portions of this application may result in processing delays or make this application impossible to process.

First Name *

M.I.

Last Name *

Preferred Name

Address *

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone *

Area Code

Phone Number

Email *

Date of Birth *

Tribal Affiliation *

Enrollment Number

Home Agency & Address *

Other Tribal Affiliation

Are you a citizen of the United States *

Yes
No

Sex *

Male
Female

Have you ever been convicted of a crime? *

If yes, explain

Are you currently on probation through the courts? *

If yes, explain

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Family Information

Did either of your parents receive a college degree?

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The Indian University of North America may communicate about your application, information relevant to the admissions process, and your college experience using the contact information you provide below.

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Parent/Guardian #1

First Name *

Last Name *

M.I.

Phone *

Area Code

Phone Number

Email *

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Parent/Guardian #2

First Name

Last Name

M.I.

Phone

Area Code

Phone Number

Email

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Emergency Contact

Same as above

Emergency Contact

Phone

Area Code

Phone Number

Email

Relationship

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EDUCATION
Please list your cumulative high school GPA and the high schools you have attended or are attending (beginning with the most recent) include your graduation date or expected date of graduation.

Cumulative GPA *

If your cumulative GPA is below a 2.6, please explain contributing factors:

College *

Address *

From *

To *

Will you graduate from this school *

Graduation Date *

College

Address

From

To

Will you graduate from this school?

Graduation Date

High School Attended *

Date of Graduation *

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AGREE TO STATEMENT OF INTEGRITY
Please review the Statement of Integrity below. Only applicants who agree to abide by the “Statement of Integrity” will be considered.

We are committed to honest, fairness, trust, respect, and taking responsibility for our actions. These values are vital to our academic community. As students, faculty, and staff of The Indian University of North America and Black Hills State University, we make firm our commitment to integrity in word, work, and conduct. We agree to represent all work honestly, to abide by the professional and ethical standards of each discipline, and to insist upon the same commitment from all members of our academic community.

I have read and agree to abide by the “Statement of Integrity” if I am accepted to the program. A check mark indicates agreement.

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INFORMATION REQUEST
The information requested below is used to comply with Title VI of the Civil Rights Act of 1964. As an applicant, responding to these questions is optional and your response will in no way affect admission. We are asking now to avoid a separate request once a student becomes enrolled. We use the data in aggregated form only to comply with federal reporting requirements.

Please indicate if you are of Hispanic/Latino(a) ethnicity *

Hispanic/Latino(a)
Non-Hispanic/Latino(a)

Please indicate your race (mark one or more) *

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SELECTIVE SERVICE
Pursuant to South Dakota Codified Law 13-52-1.1, no male person born after December 31, 1959, may enroll at any state-supported college or university until he has answered the below statement in the affirmative:

Do you certify that you are registered with the Selective Service pursuant to the Military Service Act, 50 U.S.C. 453, as amended and in effect as of January 1, 1988, or that for a reason specified in 50 U.S.C. 453, you are not required to be registered?

I declare and affirm under the penalties of perjury that this application has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.

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PERSONAL STATEMENT AND APPROVALS TO SHARE INFORMATION

If selected and attending the WICHOZANI program, I authorize Crazy Horse Memorial Foundation to use my image, likeness, and voice recordings in their entirety or any portion thereof in connection with promoting the program and the Memorial’s events and activities. A check mark indicates agreement.

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I hereby certify that the information supplied by me to the WICHOZANI Program sponsored by the Crazy Horse Memorial Foundation, Native American Jump Start and Black Hills State University is true and correct to the best of my knowledge. My signature below also represents agreement to the Rules of Conduct and the Statement of Integrity. I also understand that if accepted to the program, I am responsible for submitting proof of required immunization and health insurance information before Nov 1st, 2024 as well as official college transcripts. Finally, my signature below authorizes Black Hills State University to share application information with the Crazy Horse Memorial Foundation and if accepted to the program, I also approve Black Hills State University to share my academic results with the Crazy Horse Memorial Foundation since they sponsor the program.

Printed Name *

Date *

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EXTRACURRICULAR ACTIVITIES & FAMILY RESPONSIBILITIES
Please list any extracurricular activities or family responsibilities that you would like to have considered. (These may include clubs, organizations, employment, caring for family members, or responsibilities held outside of school)

Activities and Responsibilities

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AWARDS & ACHIEVEMENTS
Please list any special awards, achievements, offices held, or memberships which you would like to have considered:

Awards and Achievements

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Essay
Please write an essay (250-300 words) that demonstrates your ability to develop and communicate your thoughts. Some ideas may include:

Why do you wish to participate in the WICHOZANI Program? What do you hope to contribute, and what do you hope to gain from the experience?
What extracurricular or volunteer activities have you participated in? How have those activities prepared you for leadership or service roles?
How do you define community, and how have you positively contributed to your community?
What are your future career goals? How will your intended program of study (degree) assist you in achieving your career goals?

Essay *

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DISCLAIMER AND AGREEMENT

If this application leads to admission, I understand that false or misleading information in my application or interview may result in my release.

I certify that my answers are true and complete to the best of my knowledge.

E-Signature *

Agreement Date *