Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
*
ARE YOU SIGNING UP TO BE A PARTICIPANT OR A VOLUNTEER?
*
Preferred adventure date?
*
MM
DD
YYYY
Weight
*
Do you have a physical disability or chronic/terminal illness?
*
IF YES EXPLAIN
*
If you have a personal care assistant, will they be accompanying you on your adventure?
Caretakers are welcome and the trip is free for them as well
Are you a military veteran?
*
What branch of the military did you serve?
How many years of service?
Can you provide us a copy of your DD214?
Was your discharge honorable or dishonorable?
IF DISHONORABLE PLEASE EXPLAIN
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Is your vehicle a...
*
Does your vehicle have 4-wheel drive or All Wheel Drive?
*
HOW DID YOU HEAR ABOUT COURAGE INCORPORATED?
WHAT ARE YOUR OUTDOOR INTERESTS?
Coffee
Regular
Decaf
List Your Food Allergy and indicate if mild, moderate, or severe.
Diabetic? No Gluten? Peanut Allergy? No seeds? Shellfish? Etc
MUST HAVES
Need a banana every morning? Only eat oatmeal? Can't live without a certain snack or treat? Let us know here!
DISLIKES
Please don't make me eat this! Tell us what you can't or won't eat here
**FOR ICE FISHING EXCURSIONS PLEASE DISREGARD THE QUESTIONS BELOW PERTAINING TO SLEEPING/TENT ACCOMMODATIONS**
Please choose your sleeping platform
Cot
Cot with sleeping pad
Conventional Air Mattress
Furniture Accessories
Need a table in your tent? A chair? Check what you need below
SPECIAL REQUESTS FOR YOUR TENT
Have a special request for something you'd like in your tent? Let us know below
*WAIVER* I hereby waive the organizer(s) [Courage Incorporated and its members, officers, directors] and volunteer(s) of this event from any liability of injury, death, loss of, or damage to personal property associated with activities during this event - even in circumstances that are at the negligence of the organizer and/or volunteer(s). I understand that participation in the programs being offered are at my own risk. By participating in or attending any activity in connection with this program, whether on or off the premises, I understand that there may be pictures, video, and/or audio taken of me. Furthermore, I consent to the use of any photographs, video, and/or audio taken of me or provided by me for publicity, promotion, television, websites or any other use, and expressly waive any right of privacy, compensation, copyright or other ownership right connected to said media. By typing your name into the box below you agree that you understand these statements and agree that typing your name is equivalent to affixing your signature at your own free will. PLEASE TYPE YOUR NAME IN THE BOX BELOW
