Hunt of A Lifetime Youth Referral Application
  
Applicants Information (Please enclose a picture for our files. Thank you)

Name:

 

D.O.B./Age:

 
Social Security #:   -   -  

 Sex: 

M     F 
Height:  

 Weight:

  

 Eyes:

  

 Hair:

  
Illness:     Is this a RUSH dream:  
Clothing Sizes:   Jacket-    Pants-    Boots-  
Parents/Guardian Information
Fathers Name:  
Mothers Name:  
Address:  
Address:  
City:    State:    Zip:  
City:    State:    Zip:  
Phone:  
Phone:  
E-mail:  
E-mail:  
Is this Individual aware of the life-threatening condition?  
Medical Information
Physician Name:  
Address:   City:    State:    Zip:  
Office Telephone:     Fax:  
Treatment Facility/Hospital:  
Summary of Physical limitations:  
  
  
Special Needs or Accommodations:  
   
NOTE: Physicians please ATTACH a statement as to the type of Life-Threatening/Terminal illness the applicant has.
Dream Information
What type of Dream does the youth want?       Hunting     Fishing 
What Species:   1.   2.   3.  
State/Country Preference:   1.   2.   3.  
Has the youth ever hunted/fished before?    Do they presently have a license to Hunt/Fish?  
Have they ever had a hunter safety course?    If so, When?   (Please attach a copy of the certificate.)
Have you ever participated in other programs such as this?     If yes, please explain:  
 
How did you hear about the Hunt of A Lifetime: