Walleyes for Wounded Heroes Staff, Volunteers and Boat Captain Registration Form

Walleyes for Wounded Heroes Staff, Volunteers and Boat Captain Registration Form
Code of Conduct *

I have read and will abide by Walleyes for Wounded Heroes Code of Conduct Policy
I am... (Please check one) *

Staff (Board Member) Boat Captain First Mate Volunteer Other
Boat Captains Name (If First Mate):
Last Name: *
First Name: *
Sex: *

Male Female
E-mail *
Phone Number: *

Area Code Phone Number
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Restrictions:
Anyone you would like to bunk with?
Branch of Service:

Army Navy Marines Airforce Coast Guard
Please Check All That Appy:

Combat Veteran Purple Heart Honorable Discharge
Duty Status:

Active Inactive
Service Start Date:
Service End Date:
First Responder Information (if applicable):

Police Fire EMS Disabled
Tee Shirt Size *
List prior years of attendance:

2020 June Event 2020 Fall Event 2019 June Event 2019 Fall Event 2018 June Event 2018 Fall Event 2017 June Event 2017 Fall Event 2016 June Event 2016 Fall Event
Primary Emergency Contact: *
LastName, FirstName
Relationship *
Email *
example@example.com
Phone Number *

Area Code Phone Number
Secondary Emergency Contact:
LastName, FirstName
Relationship
Email
example@example.com
Phone Number

Area Code Phone Number
Comments: (include any special medical or personal information you would want an emergency care provider to know – or special contact information, i.e. medications, allergies, surgeries, etc.)
Comments
Once you submit your application, we will contact you shortly

Thank you!
Should be Empty: