Oaye Luta Okolakiciye Cultural ServicesSelf-Referral

Oaye Luta Okolakiciye

Cultural Services

Self-Referral

If you are experiencing an emergency contact 911 immediately.

If you would like to have a conversation about receiving cultural services, please complete this form.

Wopila / Thank you

Date*

Contact Name*

Preferred Name

Given/ Spirit Name

Gender Identity (select all that apply)*

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Date of Birth*

Do you have a phone number?

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Phone Number

Reason For Referral

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Tribal Affiliation

Physical Street Address

Physical Address City

Physical Address State

Physical Address Zip Code

Mailing Address

Best way to communicate*

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Best time to communicate

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Are you over the age of 18?

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Parent/ Guardian Name (if minor)

Parent Guardian Mailing Address

Parent Guardian Phone

Parent Guardian Email

Second Parent/ Guardian (if minor)

Second Parent/ Guardian Phone

Second Parent/Guardian Email

Second Parent/ Guardian Mailing Address

Mother's Name

Maternal Grandparents' Name (if known)

Father's Name

Paternal Grandparents' Name

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Address

Emergency Contact Relationship

School/ College Name

Is the relative in school?

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Grade/ Year

Major

Employment Status

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Cultural Services Requested

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Details of the Cultural Request

Has the relative participated in an inipi?

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Does the relative have a feather and/or plume?

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Is the relative afraid of the dark/ close?

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Name of Person Completing Form

Phone number of person completing the form

Email address of person completing form

Other Comments

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