By filling out the information below, you are asking Dreams For Kids Network, Inc. to help make your dream come true and are making a commitment to do your best everyday at home, in school and in the community. If we see that you are committed to doing your best, we will do our best to help make your dream come true!

Your Dreams Form
Student First Name:
Student Middle Name:
Student Last Name:
Student Address:
Student City:
Student State:	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Student Zip:
Student Home Phone:	( ) -
Student Other Phone:	( ) -
Student Email:
School:	Select One Bookcliff Middle School Central High School East Middle School Fruita 8/9 School Fruita Middle School Fruita Monument High School Gateway School Grand Junction High School Grand Mesa Middle School Mount Garfield Middle School Orchard Mesa Middle School Palisade High School R5 High School Redlans Middle School Valley School East Valley School West West Middle School Other
Grade Level (5-12):	Select One 6 7 8 9 10 11 12 Other
Age:
Parent/ Guadian Information
First Name:
Middle Name:
Last Name:
Work Phone:	( ) -
Other Phone:	( ) -
E-mail:
Plaese answer and explain the questions below as best as you can. The more information you provide to us about your dream, the more we can do to make your dream come true!
Is your dream for yourself or someone else?
Select One Myself Family Member Friend Other
What is your dream?
Choose the category that best fits your dream:
Select One Do Something Get Something Give Something Learn Something Meet Someone Travel Somwhere Other
How do you think having your dream come true will effect your life?
Tell us about yourself and your family.