BackCountry Heroes Veteran/First Responder Intake Form

BackCountry Heroes Veteran/First Responder Intake Form
Please SEND OF COPY Of:

DD-214 (SSN BLACKED OUT) Active Duty ID (front only) or Current Department or Retirement Credentials

Drivers License (front only)

Go ID or Hunter Safety Certificate to Info@backcountryheroes.org

*Filling out this form does not guarantee participation in an event.
Full name
Phone Number:
Email Address:
Date of Birth:
Location (City & State)
Which Best Describes You?
Branch of Service & MOS/Job Title. If Active Duty or Currently Working as a First Responder Please Specify Job
Are You Retired?
Discharge Type:
Do You Have Any of The Following Diagnosis?

Other
Consent To A Background Check?:
Please Tell Us A Little About Yourself:
Do You Have A Valid Hunting License or Hunter Safety Certification?
What are you interested in doing?
What are you interested in hunting?
Emergency Contact Name & Number:
Food Allergies? Please List:
Should be Empty: