Cora's Kids Application 2017
Thank you for your interest in the Cora's Kids 2017 program. Please fill out this entire application and click Submit when complete.

The application deadline is May 12th, 2017.

Program is held June 13th-16th 2017
Cora’s Kids is a day program held at the Dream of Wild Health organic farm in Hugo, MN. Participants will grow and eat healthy indigenous food and learn traditional agriculture, games and activities.

PICK UP LOCATIONS - Youth will choose one
Little Earth of United Tribes main office 2501 Cedar Ave S Mpls 55404 UP- 8:00am OFF 4:00pm
American Indian Family Center 579 Wells Street St Paul MN 55430 UP- 8:30am OFF 3:30pm

Notification letters and additional information will be mailed May 22, 2017.
Space is limited to 14 Native American children.

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Child's Name
Your answer
Gender of Child
Your answer
Date of Birth
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DD
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YYYY
Age
Your answer
Tribal Affiliation
Your answer
Town (Tribal Affiliation)
Your answer
State (Tribal Affiliation)
Your answer
School
Your answer
Grade in School
Your answer
Qualify for Free & Reduced Lunch
Does the applicant qualify for free and reduced lunch at school? Checking yes does not necessarily mean the applicant receives free or reduced lunch, just that they qualify to be a recipient.
Legal Guardian Name(s)
Your answer
Legal Guardian Email
Your answer
Would you like to receive our e-Newsletter at the previously listed email?
If you check yes, we will add your previously listed emails to our e-mailing list.
Legal Guardian Phone Number(s)
Your answer
Parent/Guardian Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Emergency Contact Info (Name)
Your answer
Emergency Contact Info (Relationship to Child)
Your answer
Emergency Contact Info (Phone)
Your answer
Child's Doctor or Clinic (Name, Address, AND Phone Number)
Your answer
Does your child have any allergies or dietary needs we need to be aware of (Especially food and bees)? If yes, please explain.
Your answer
Does your child have any health or behavior challenges that we need to be aware of?
Your answer
Signature of Permission & Date
I give my child permission to participate in Cora’s Kids in Summer 2017. I give Dream of Wild Health permission to teach, feed, transport and photograph my child. Dream of Wild Health will not be held liable for any injuries that may occur in the event of an unforeseen accident. ***By typing my name below, it indicates my electronic signature.***
Your answer
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