New Member
Fill out this form to become a member. This online enrollment should be completed only by individuals who can legally document their Chitimacha ancestry. Must be 21 years of age to complete this form
Email address *
First Name *
Middle Initial *
Last Name *
Maiden Name *
Chitimacha Descendants (List 4-5 Generations) *
Phone Number *
Street Address *
City *
State *
ZIP Code *
Date of Birth *
Are you state or federally recognized by an Indian tribe? *
If yes, which tribe? (N/A if no) *
The information provided may be included in federal litigation. The code section criminalizing false statements to the federal government can be found under 18 U. S. C. §1001. To ensure the validity of the information collected, please check to confirm the following statement: *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Department of Design.