Outdoor Adventure Application

*OUTDOOR ADVENTURE AND ADAPTIVE EQUIPMENT APPLICATION
*ALL INFORMATION PROVIDED WILL BE TREATED AS PRIVATE IAW WITH HIPPA*

Name * First Last
Gender * Male Female
Date of Birth *
Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Alternate Phone - (###) - ### ####
Mobile Phone - (###) - ### ####
Email Address *
Alternate Email
Occupation/Title/Rank *
Marital Status *
Media Willingness * Yes No
Alternate/Emergency Contact *
Relationship to Emergency Contact *
Emergency Contact Phone * - (###) - ### ####
Service * Military Police EMS Firefighter
If Military Selected Above, Please Indicate Branch of Service
Service Status * Active Medically Retired Retired Other
If you selected Other above, please explain
Date of Injury-Disability-Disease *
Location of Injury-Disability-Disease (IRAQ, AFGHANISTAN, STATESIDE, OTHER) *
Type of Injury/Disability/Disease *
Are You Receiving Inpatient/Outpatient Care? * Yes No
Name and Location of Treatment Facility (If Yes above)
Name of Current Physician and Contact Information
Date of Last Treatment or Next Scheduled Visit
Type of Injury * Amputee Visually Impaired PTSD Spinal Cord Injury Shell Fragment Wound/Gunshot Wound TBI Disability Disease Other
If Other Selected above, please indicate
Injury/Disability/Disease Description *
OTHER INFORMATION OR MEDICAL NEEDS THAT MAY BE PERTINENT TO OUR STAFF DURING YOUR VISIT
Applying For * Outdoor Adventures Upland Bird Hunt Clay Target Shoot Fly Fishing Rental of Adaptive Equipment (All-Terrain Wheelchair)
Occupation/Title/Rank *
Select All That Apply * I CAN WALK LONG DISTANCES WITHOUT ASSISTANCE I NEED ASSISTANCE FOR LONG DISTANCES AND HELP CLIMBING I NEED USE OF (ALL TERRAIN WHEELCHAIR)
Will you bring your own clothing/equipment? * Yes No
PLEASE LIST YOUR SIZES REGARDLESS OF WHETHER YOU CHECKED YES OR NO ABOVE for the following:
Pants Waist, Pants Length, Shirt, Jacket, and Shoes *
Have you hunted/fished before? * Yes No
What game have you hunted before? * Big Game Small Game None
List the game you have hunted *
DO YOU HAVE ANY SPECIAL TRAINING (FOR EXAMPLE, FIRST AID, CPR, WATER LIFE SAVING, ETC.)? *
*IT IS VITALLY IMPORTANT THAT WE KNOW IF YOU HAVE ANY PHYSICAL PROBLEMS AND/OR ISSUES WE COULD EXPECT TO ENCOUNTER. IN THE SPACE PROVIDED BELOW, PLEASE LIST ANY PHYSICAL PROBLEMS OR DEFICIENCIES THAT YOU MAY HAVE (for example, breathing problems, diabetes, allergies to a bee or wasp sting, allergies to foods, allergies to medications, allergies to environment [e.g., hay fever, animals, etc.], food or leg weakness, night blindness, extreme fear of heights, etc.) THIS INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL, BUT WE MUST KNOW ABOUT IT BEFORE YOU ARRIVE. *
ADDITIONAL NOTES:
*PLEASE BRING A COOLER FOR YOUR GAME.
How did you hear about Wings for Our Heroes? * Newspaper Website Fellow Warrior Internet Friend/Relative Other
If Other selected above, please list here
*YOUR DIGITAL SIGNATURE BELOW ACKNOWLEDGES THAT YOU HAVE READ AND UNDERSTOOD THIS APPLICATION AND THAT YOU AGREE TO NO ALCOHOL OR DRUG USE 8 HOURS PRIOR TO THE AWARDED OPPORTUNITY (OUTDOOR ADVENTURE / HUNT). MEDICAL OR PSYCHOLOGICAL EVALUATION MAY BE REQUIRED PRIOR TO ANY GRANTED OPPORTUNITY. PICTURES, VIDEO AND ALL SOCIAL MEDIA WILL BE PERMITTED AND AT THE DISCRETION OF WINGS FOR OUR HEROES UNLESS OTHERWISE AGREED UPON. EMERGENT MEDICAL CARE WILL BE AVAILABLE DURING GRANTED OPPORTUNITIES, SIGNATURE AUTHORIZES SUCH CARE IN THE EVENT THAT YOU ARE UNABLE TO PROVIDE VERBAL CONSENT.
Your Full Name Here Serving As Your Digital Signature *
Type the letters you see in the image below.

Outdoor Adventure Application

Outdoor Adventure Application

ADDITIONAL NOTES: *PLEASE BRING A COOLER FOR YOUR GAME.

ADDITIONAL NOTES:
*PLEASE BRING A COOLER FOR YOUR GAME.