Form IHS-856-21 Summer School Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

FORM APPROVED:
OMB Approval No. xxxx-xxxx
Exp. Date: x/xx/xxxx
See Estimated Average Burden Time
per Response on Reverse Side.

PUBLIC LAW 94-437 – TITLE I SCHOLARSHIP PROGRAM

SUMMER SCHOOL REQUEST
A Summer School Request must be received by your IHS Scholarship Program analyst by April 22
in order for an applicant to be eligible for Summer School.
RECIPIENT’S NAME

SOCIAL SECURITY NUMBER

ADDRESS

PHONE: CELL

CAREER CATEGORY

SCHOLARSHIP PROGRAM:

IHS AREA OFFICE

Preparatory

Home

EMAIL ADDRESS

Pre-Graduate

Health Professions

Type of Summer School Request:  Repeat/Curriculum Required Course Work
Year Round Curriculum (use back of form)
Enrollment Status:

Full-time

Part-time

EXPLAIN YOUR REQUEST FOR APPROVAL TO ATTEND SUMMER SCHOOL:

Repeat/Curriculum Required Course Work
(Please include all courses required)

SUMMER SESSION I:
COURSE NUMBER

FROM

SUMMER SESSION II:
COURSE NUMBER

To

TITLE

HRS.

FROM

To

TITLE

HRS.

YOU MUST SUBMIT DOCUMENTATION TO SUBSTANTIATE THESE COURSE REQUIREMENTS.
FUNDING REQUESTED (Must include tuition amount for each session):

SUMMER SESSION I

SUMMER SESSION II

TUITION
FEES
TOTAL

Required signature on back of this form
IHS-856-21

EF

Year Round Curriculum
(Please include all courses required)

SUMMER SESSION I:
COURSE NUMBER

FROM

HRS.

SUMMER SESSION II:
COURSE NUMBER

To

TITLE

FROM

To

TITLE

HRS.

YOU MUST SUBMIT DOCUMENTATION TO SUBSTANTIATE THESE COURSE REQUIREMENTS.
RECIPIENT’S SIGNATURE

DATE

ADVISOR’S NAME (Print)

DATE

ADVISOR’S SIGNATURE



PHONE:

Return to:
IHS Scholarship Program
Attn: Program Analyst
801 Thompson Ave., Suite 120
Rockville, MD 20852

Reviewed (IHS use only): 
Analyst, Branch Chief or Designee

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 6 minutes per response including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to Indian Health Service, IHS Scholarship Program, 801 Thompson Ave.,
TMP-450, Rockville, MD 20852.