Long Winter Get Away

Name

First

Middle

Last

Address

City

State/Province

Zip/Postal

Country

Phone

Age

Weight

Email

In case of emergency, please contact:

Emergency Contact Phone #

Type of disability/diagnosis:

Briefly describe physical disabilities:

Difficulties with outdoor temperatures?

Yes

No

Describe any special needs, assistance, and/or equipment you will need:

Do you require the use of a wheelchair for independence?

Yes

No

Items Used

If other, please describe:

Are you able to climb into a bunk bed?

Yes

No

Please list any current medications

Date of last medical appointment?

Name of physician seen:

List any allergies (be specific)

Please list any other medical information concerning your current health status:

What was the last year you fish/hunted?

Last year you fired a weapon independently:

Do you have a fishing pole available to use?

Yes

No

Branch of Service

Rank

Years Served

Deployments:

Applicant's Signature