Safari Application

Please fill out application completely, if you have any questions please contact [email protected]
Safari Application
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country
Are you a Minnesota Resident?
Did You Serve in Combat?
Gender
Military Status
Do you have a passport?
If no, are you willing to obtain one?
Do you have a VA Rated Disability?

Please rate the following:

Do you use adaptive or mobility devices?
Are you currently taking prescription medications?

Emergency Contact Information

Name
Name
First
Last

Signature

Maximum file size: 5MB