Please complete and submit the application below by 5 p.m. CDT on Wednesday, May 9, 2018. You must be at least 18 years old to submit an application. If you have any questions, please contact shirley@echohawkconsulting.com.

* 1. First Name

* 2. Last Name

* 3. Tribal Affiliation

* 4. Please indicate your age range below:

* 5. E-mail Address

* 6. Address

* 7. City

* 8. State

* 9. Zip Code

* 10. Organization

* 11. Phone Number (XXX) XXX-XXXX

* 12. What is the mission or the role your organization plays in your community?

* 13. Please briefly describe the work that you and your organization do.

* 14. Please briefly describe how you and your organization work to improve health in the community.

* 15. What are the three biggest challenges you face in engaging your community?

* 16. How can the Fertile Ground Leadership Institute help build the capacity of your leadership as you work to improve health in your community?

* 17. Please list previous trainings that you have attended.

* 18. The Fertile Ground Leadership Institute will be offered in Minneapolis/Saint Paul, Minnesota, on June 11-13, 2018 and in Seattle, Washington, on August 7-9, 2018. Please indicate below which training you are available to attend if you are selected. The Institute will cover roundtrip airfare, accommodation, meals, and reimburse travel to and from the airport based on accepted travel policies.

* 19. How do you hear about the Leadership Institute?

Thank you for submitting your application for the Fertile Ground Leadership Institute! We will notify all applicants of their final status by the week of May 21. 
 
100% of survey complete.

T