BHA Student Information Form
Please answer the following questions:
Preferred Name // Nickname
Tribal Affiliation
Do you prefer me to communicate to you through your work email or school email?
Work email
School email
Both
Please provide the email(s) you prefer to be contacted at.
Work Title // Position (if applicable)
How long have you been in your current role?
Date of Birth (example: 04/22/1993)
T-shirt/Hoodie Size
Do you have your Elder/Mentor?
Yes
No
Would you like help identifying/recruiting an Elder/Mentor?
Yes
No
Do you have a Clinical Supervisor?
Yes
No
Do you need help identifying a Clinical Supervisor?
Yes
No
If you do want help recruiting an Elder/mentor, what are some topics you hope to learn/share with them?
Indigenous traditional food/medicine gathering
Gardening
Beading/crafting
Sewing regalia
Public Speaking
Community leading/advocacy
Workforce development
Planning social events
Storytelling
Ceremony
Youth development
Horse medicine
Self care hobbies (talking circle/meditation/yoga/fitness)
Substance Use Disorder (SUD)/Mental health
Other
Please attach an image/headshot of yourself, if you feel comfortable.
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