Youth Dream Hunt Foundation
Referral Application
Applicants Information (Please enclose a picture for our files. Thank you.)
Legal/Full Name: ______
D.O.B. ______
Age: _____ Illness / Disability: ______
Sex (Check One): Male _____ Female _____
Height: _____ Weight: _____ Eye Color: _____ Hair Color: _____
Clothing Sizes: Jacket: ______Pants: ______Boot: ______
Hand Preference (Check One): Right Handed _____ Left Handed _____
Parents/Guardian Information (Legal names as they appear on your licenses. Nicknames may slow your application process.)
Father’s Name: ______
Address: ______City: ______
State: ______Zip: ______Phone: ______
Email: ______
Mother’s Name: ______
Address: ______City: ______
State: ______Zip: ______Phone: ______
Email: ______
Medical Information
Physician’s Name: ______Address: ______
City: ______State: ______Zip: ______
Office Phone: ______Fax: ______
Treatment Facility/Hospital: ______
Summary of Physical Limitations: ______
______
Special Needs or Accommodations: ______
______
Wheelchair Bound (Check One): Yes _____ No _____
If yes (Check One): Power _____ Manual ______
Dream Hunt Information
What type of dream does applicant have? (Check One): Hunt _____ Fish _____ Exotic Animal _____
Has the youth ever hunted/fished before? ______
Do they presently have a license? ______
Have they ever had a hunter’s safety course? ______
Do they have their own (Check One): Shotgun: _____ Rifle: _____ Fishing Pole: _____
Have you ever participated in any other program such as this? ______
Have they ever fired a weapon before? Yes_____No______
If yes, please explain: ______
Additional Information
How did you hear about Dream Hunt Foundation: ______
______
NOTE: If the child has a life threatening illness have the physician please ATTACH a statement as to the type of life-threatening/terminal illness the applicant has. Thank you!
Please initial that you understand that a physical statement must be attached to this application: ______
If the applicant has a life threatening illness, do they know about it? (Check One) Yes _____ No _____
I certify that the above is true to the best of my knowledge.
Parent Signature: ______Date: ______