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Title: Dream Hunt/Fish
Description: BULLOCH SPORTSMEN’S DEVOTIONAL, INC. www.bullochsportsmensdevotional.com Application for Dream Hunt/Fish Applicants Information Name ______________________________________ Date of Birth:___/___/_____ Age ___ Male Female Illness: ___________________________________________ If critically ill, what is the window of opportunity to participate in his/her dream: ____________ Is this individual aware of the life-threatening condition? Yes No Parents/Guardians: Mothers Name: ______________________________________________________ Address: ____________________________________________________________ City: __________________ State: ______________________ Zip Code: _________ Phone: ________________________ Mobile: _____________________________ E-mail if Applicable: ___________________________________________________ Fathers Name ________________________________________________________ Address: ____________________________________________________________ City: __________________ State: ______________________ Zip Code: _________ Phone: ________________________ Mobile: _____________________________ E-mail if Applicable: ___________________________________________________ Physician’s Name: __________________________________________________ Office Address: _____________________________________________________ City: __________________ State: ______________________ Zip Code: _________ Office Phone: ________________________ E-mail if Applicable: ___________________________________________________ Treatment Facility/Hospital: ______________________________________________ Summary of your patient’s physical limitations: _____________________________________________________________________ Special Needs or Accommodations: ______________________________________________________ Have Applicant’s Physician attach a statement as to the sort of disability or terminal illness the individual has and his/her medically-documented limitations. [Note: all information will be kept in strict confidence between Bulloch Sportsmen’s Devotional, Inc. and those immediately involved in the event itself.] General Family Related Questions: 1) What type of dream hunt or fishing trip does the Applicant want? ___________________ Deer/freshwater fishing/saltwater fishing/other _______________________ 2) Has the applicant ever participated in any form of hunting and/or fishing? Yes No Has the applicant ever partaken in a FREE hunting or fishing trip donated by anyone or any organization? Yes No If so when, __________ and since their disability or illness was diagnosed, how many hunting and/or fishing trips did the applicant attend? __________ 3) Has the applicant ever attended a hunter safety course? Yes No If so, does he or she hold a certificate? Yes No [Note: Firearm safety is an important part of a successful hunt and is required in most states.] 4) Does the applicant have a suitable firearm for his/her particular wish? Yes No 5) If the applicant chooses a fishing dream, does he or she have suitable tackle and rod and reel? Yes No 6) Will the applicant need wheelchair accessibility to blinds, boats, etc.? Yes No 7) Can you afford any incidentals our of pocket costs such as fuel or motel? Yes No Bulloch Sportsmen’s Devotional will try to keep all dream events with in a 250 mile radius of applicants’ home. Our goal is to help keep costs moderate so we can have funds available for more dream events. NOTE: IF POSSIBLE PLEASE INCLUDE PICTURE(S) OF APPLICANT Any Additional Comments: AMERICANS WITH DISABILITY ACT 1990, Bulloch County Sportsmen’s Devotional prohibits discrimination against disabled people and guarantees equality of opportunity for people with disabilities as well as the terminally ill to engage int hunting and/or fishing adventures. WAIVER OF LIABILITY: Bulloch Sportsmen’s Devotional, Inc. is a non-profit organization seeking to grant wishes for people with a life threatening illness seeking to participate in a major hunting or fishing expedition. To that end, Bulloch Sportsmen’s Devotional, Inc. requires the execution of this comprehensive waiver as follows: The undersigned agrees that he/she, along with his/her successors, heirs, and assigns to hold harmless and forever indemnify the Bulloch Sportsmen’s Devotional, Inc., its Board of Directors, Agents, and Collaborators from liability associated with any death resulting from, or in association with, or during the execution of the event as set forth and otherwise facilitated by Bulloch Sportsmen’s Devotional, Inc. The undersigned also agrees that he/she along with his/her successors, heirs, and assigns to hold harmless and forever indemnify the person or persons offering the hunting or fishing trip, namely Bulloch Sportsmen’s Devotional, Inc., its agents and collaborators from any and all liability associated with any injuries sustained in association with, or during the execution of the event as set forth and otherwise facilitated by Bulloch Sportsmen’s Devotional, Inc. This instrument shall be applicable to any accident, injury, or event that occurs in 2009 or succeeding years. The undersigned personally accepts all liability and responsibility for the actions of everyone hunting or fishing with him or her (including minors, friends, associates, guest, etc.) THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAVIER OF LIABILITY AND INDEMNITY AGREEMENT, and further states that no oral representations, statements, or inducements apart from this agreement have been made. Date __________________ Name _____________________________________ Address ______________________________________ City ____________________ State _____ Zip Code _________ Phone _________________________ Signature ___________________________________________ Parents (signature if under 18) __________________________________________ State of ___________ County _______________ SUBSCRIBED and SWORN before me this _____ day of ___________ 200_ ________________________________ Exp. Date _________________________ NOTARY PUBLIC [Please make sure this application is signed before notary public] BULLOCH SPORTSMEN’S DEVOTIONAL, INC. 600 Park Ave; Statesboro, GA 30458-5114; (912) 764-5407; Cell (912) 682-3863 www.bullochsportsmensdevotional.com E-mail claude@bullochsportsmensdevotional.com