Outdoor Adventure and Adaptive Equipment Application

ALL INFORMATION PROVIDED WILL BE TREATED AS PRIVATE LAW WITH HIPPA

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Name *

First

Last

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Gender *

• Male
• Female

Date of Birth *

Mailing Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

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Primary Phone Number *

Alternative Phone Number

Email Address *

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Marital Status *SingleMarriedWidowedDivorced/Separated

Occupation/Title/Rank *

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Type of Service *

• Military
• Police/Corrections
• EMS
• Firefighter

Please Indicate Branch of Military Service *

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Service Status *

• Active
• Medically Retired
• Retired
• Other

Please explain "other" service status *

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 *

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Date of Injury/Disability/Disease *

Location of Injury/Disability/Disease *

(IRAQ, AFGHANISTAN, STATESIDE, OTHER)

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Are You Receiving Inpatient/Outpatient Care? *

• Yes
• No

Name and Location of Treatment Facility *

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Name of Current Physician and Contact Information *

Date of Last Treatment or Next Scheduled Visit *

Other information or medical needs that may be pertinent to our staff during your visit

Applying for *

• Outdoor Adventures
• Upland Bird Hunt
• Fly Fishing
• Rental of Adaptive Equipment (All-Terrain Wheelchair)

Select all that apply *

• I can walk long distances without assistance.
• I need assistance for long disances 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 *

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What have you hunted/fished before? *

• Big Game
• Small Game
• Fish
• None

List the game you have hunted *

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Do you have any special training? *

• Yes
• No

(For example, First Aid, CPR, Water Life Saving, etc)

Please list special training *

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Alternate/Emergency Contact *

Relationship to Emergency Contact *

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Emergency Contact Phone *

Are you willing to participate in Wings for Our Heroes media/press?

• Yes
• No

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.

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How did you hear about Wings for Our Heroes? *

• Newspaper
• Website
• Fellow Warrior
• Internet
• Friend/Relative
• Other

If Other selected above, please list here *

BY CHECKING THE BOX BELOW, YOU ACKNOWLEDGE 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. CHECKING BOX AUTHORIZES SUCH CARE IN THE EVENT THAT YOU ARE UNABLE TO PROVIDE VERBAL CONSENT. *

• I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS APPLICATION.

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