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.)

* 1. What is the name of child?

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

* 3. What is child(ren) age?

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

* 5. What is child(ren) grade?

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

* 7. What is school name?

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

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

* 10. Please enter household contact information.