*Name of youth
*Birthdate
*Address
*City
*State
*Zip
*Parent/guardian name
Address (if same leave blank)
City
Zip
Best time to call
*Email address
Person making referral
Relationship to youth
Referral phone
Diagnosis/physical ability
The youth Is Ambulatory (walk) Electric wheelchair Manual wheelchair
Prosthetics
Youth is interested in hunting fishing camping
Other (specify)
Adaptive equipment
Please specify any specialized seating needed to ride in an ATV type vehicle.
List any allergies
Does the youth have any communication limitations? yes no
Has the youth ever been hunting? yes no
If yes, please describe hunt
Has the youth ever shot a gun? yes no
What caliber/gauge?
Are shooting aids required? yes no
Has the youth ever shot a bow? yes no
Has the youth ever been fishing? yes no
A guide will be with each participant during the hunting/fishing trip. Is there any other individual the youth will need to accompany them, if possible? yes no
If yes, please name the individual
Are there any special accommodations needed with lodging? yes no
If yes, please specify
Please list any hobbies the youth has
List include any other information which will assist us in making this decision
*Required
