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Name:
Date of Birth:
Street Address:
City:
State:
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AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
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Zip:
Primary Phone:
Choose one:
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Cell
Work
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Secondary Phone:
Choose One:
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Email Address:
Are you more interested in hunting or fishing?
Hunting
Fishing
Are you disabled?
Yes
No
If yes, are you in a wheelchair?
Yes - Electric
Yes - Manual
No
Percentage of time confined to a wheelchair?
Do you require the assistance of a caretaker?
Yes
No
If yes, will your caretaker be able to accompany you on the trip?
Yes
No
Please provide a detailed history of your disability or illness, including any limitations that would need to be accommodated:
Do you have reliable transportation to/from the hunting or fishing location?
Yes
No
If yes, how many miles are you willing to travel in your own vehicle?
Are you a veteran?
Yes
No
Have you been convicted of a felony? *Your response to this question is not a determining factor in whether or not your application is chosen
Yes
No
Do you have any allergies?
Yes
No
If yes, please describe your allergies.
Please tell us about yourself - previous participation in outdoor hunting or fishing activities, including what you have harvested and when, and what this opportunity represents to you (minimum of 100 words):
Submit
Woods & Waters Outdoor Ministries | P.O. Box 285, Springfield, LA 70462 | info@woodsandwaters.org