Child's Legal Name *

First Name

Last Name

Primary Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Birthdate *

MM

DD

YYYY

Sex *

Male

Female

If the applicant has a life threatening disease, do they know about it?

Yes

No

Wheelchair Bound? *

Yes

No

If Wheelchair Bound, is it Power or Manual?

Power

Manual

If applicant can walk, are there limitations?

Yes

No

Does the applicant have any allergies or dietary restrictions? *

Yes

No

What type of dream does applicant have? *

Please choose one

Hunting

Fishing

Exotic Animal

Can applicant follow basic commands? *

Yes

No

Has applicant ever hunted before? *

Yes

No

Has applicant ever fired a weapon before? *

Yes

No

Has applicant ever killed a deer before? *

Yes

No

Can applicant hold a gun? *

Yes

No

Can applicant pull a trigger? *

Yes

No

Can applicant climb stairs or ladders? *

Yes

No