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Wheelchair Handicap Outdoor Lifestyle Experiences

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Adventure Application We at Whole Outdoors will make every effort to ensure the health and well being of our participants, families, and volunteers. Please answer ALL questions completely when applying for a Whole Outdoors adventure experience. We must know the type of adventure experience you are applying for (i.e., hunting, fishing, camping, beach, etc.). You can find more information about our adventure offerings by going to our Adventure Page on our website at wholeoutdoors.org.

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Participant's Name *

First

Last

Phone Number *

Email *

Address Line 1 *

Address Line 2

City, State, Zipcode *

Participant's Date of Birth and Age *

Parent/Guardian Name and Phone Number (if under 18 or legally incapacitated) *

Accompanying Caregiver/Family Member’s Name, Age, and Phone Number *

Will you require any special equipment to participate in this event? (Please describe in detail) *

If you have any special adaptive equipment that you will bring, please describe in detail *

Please describe your disability or special need and history of how it occurred:

How long have you been disabled/ill? *

Wheelchair Type? *

Electric or Manual? *

Width of Wheelchair? (Widest Point) *

TOTAL Weight of Wheelchair AND Participant *

Does the Participant Have any Behavioral Issues (i.e., anger, sudden outbursts, violent, etc.): (If you answered YES above, please describe in detail and advise if participant controls said behavioral issues with prescribed medications or other coping mechanisms): *

Do you have a firearm/bow/rod & reel that you will bring to use? *

Yes
No

If you answered YES above, please describe item you will bring

Have you ever participated in a Whole Outdoors Adventure? If so, please list date and type *

Describe any Restricted Diet you Have *

Do You Have any Food or Medication Allergies? If so, Please List *

What Mode of Transportation Will You Use to Get to the Event *

outbursts, please event

Please Describe any mobility and/or other Challenges *

Please List any Other Special Accommodations Needed *

Please List Any Special Medical Attention that Might be Needed During an Adventure *

Please List Participant’s Religious Affiliations, if Any *

Please List Any Other Information that Would Help us Make Your Experience as Meaningful as Possible *

Please Select the Adventure Experience you are Most Interested in *

Hunting
Fishing
Camping
Beach Day

Has Participant Ever Fired a Rifle or Shotgun? *

Yes
No

Has Participant Ever Harvested an Animal? *

Yes
No

PLEASE READ: By submitting this application for Whole Outdoors Adventure Experiences, the applicant and all parties involved agree that this information is true and correct. The applicant and all parties involved also gives Whole Outdoors permission to use photographic images or videos for the coordination and promotion of the event applied for or any other promotional advertisements of Whole Outdoors. *

Agreed

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