Survey

This statistical information is Critical in creating nationwide opportunities to help Off-Reservation MHA Enrolled youth. These numbers will identify the need and will be assessed accordingly. (For children from grades K - 12 within current household.)

What is the name of child?

Question Title

* 1. What is the name of child?

Enter additional children if necessary. Ex: Child 8, John Doe

Question Title

* 2. Enter additional children if necessary. Ex: Child 8, John Doe

What is child(ren) age?

Question Title

* 3. What is child(ren) age?

Enter additional age(s) if necessary. Ex: Child 8, 12

Question Title

* 4. Enter additional age(s) if necessary. Ex: Child 8, 12

What is child(ren) grade?

Question Title

* 5. What is child(ren) grade?

Enter additional grades if necessary. Ex: Child 8, 10th

Question Title

* 6. Enter additional grades if necessary. Ex: Child 8, 10th

What is school name?

Question Title

* 7. What is school name?

What is location of schools at which children attend?

Question Title

* 8. What is location of schools at which children attend?

Enter additional locations if necessary, Ex: attending in/out of state private school. (City, State)

Question Title

* 9. Enter additional locations if necessary, Ex: attending in/out of state private school. (City, State)

Please enter household contact information.

Question Title

* 10. Please enter household contact information.

T