NPLB Veteran Registration Form

Which event are you hoping to attend?

If unknown, type "unspecified"

How did you hear about us?

Name*

First NameMiddle InitialLast Name

Prefer to be called:

Name

Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth*

MonthDayYear

Phone Number:*

E-mail*

example: mike@yahoo.com

Shirt Size?

Is the event you are hoping to attend in your area?*

I can drive and don't need a hotelI can drive but will still need a hotelI need to fly and need a hotelOther

Preferred Departure Airport:

Alternate Departure Airport:

Date of Birth

MonthDayYear

Gender

TSA PreCheck #

Example: 218321953

Military Status*

Service Branch*

Rank*

Purple Heart Recipient?*

YesNo

Theater of Operation (Check all that apply)

Disability Rating (If applicable)

Briefly describe your injuries.*

List any physical restrictions or special needs including diet restrictions.*

Will you have a service/companion dog with you during the event?*

YesNo

Note that some trips/events may not be conducive to service animals.

In case of emergency...

Are you currently taking any medications?*

YesNo

Please list them here:

Emergency Contact:*

First NameLast Name

Relationship

Example: Spouse

Phone Number*

E-mail*

example: mike@yahoo.com

Are you hoping to attend a hunting or fishing trip?*

YesNo

Do you currently have an active hunting license with all necessary stamps and endorsements for the state the event is in?

YesNo

Have you ever had a hunting license?*

YesNo

Please provide your DNR ID# and issuing state:

Example: 483952 (MD)

Have you completed a hunters safety course?*

YesNo

Please provide your card # and date: *

Example: 535912 (10/15/2006)

Full MOS # as shown on your DD214: *

Example: 12B30

Last four of your Social Security #:*

Drivers License #*

Example: K-364-589-147-682

Issuing State:*

Example: Maryland

Note that some trips/events may not be conducive to having an accompanying caregiver. Each guest must submit an event release form.

Will you have a guest or caretaker with you?*

YesNo

Guest's Name*

First NameLast NameRelationship

Guest Contact Number:

Area CodePhone Number

E-mail

example: mike@yahoo.com

Date of Birth*

MonthDayYear

Gender*

Will your guest be flying as well?*

YesNo

Preferred Departure Airport:*

Alternate Departure Airport:

TSA PreCheck #

Example: 218321953

Will you have any other guests with you?*

YesNo

Third person

First NameLast NameRelationship

Fourth person

First NameLast NameRelationship

Active Duty Unit

Active Duty Commanding Officer

Duty Phone #

Upload DD214

Upload VA Rating Letter (If Applicable)

Carefully read and sign the section below

TRIP RELEASE FORM:

The undersigned acknowledges that his/her participation in a retreat or an event involves certain inherent risks of physical injury, illness and/or loss of personal property.

The undersigned also affirms all statements contained in this application are true and correct and understand that false or inaccurate information will be the basis for denial and/or revocation for all support provided by Operation NPLB Outdoors.

The undersigned by his/her execution of this trip release form hereby releases and holds harmless and forever discharges Operation NPLB Outdoors and its officers, employees, directors, agents, volunteers, property owners, and staff from any and all claims, causes of action of whatsoever kind of nature, foreseen or unforeseen, arising from or in any way connected with a retreat or event.

The undersigned further recognizes that if not for his/her execution of this release form, Operation NPLB Outdoors would not permit participation in a retreat or event.

The undersigned grants permission to use his/her image on photographs and/or video taken at NPLB Outdoors events in publications, news releases, online and in other communications related to the mission of NPLB Outdoors, at the discretion of NPLB Outdoors and without payment or other consideration.

The undersigned further certifies that he/she is an adult and has read the above information carefully before his/her execution of same and that he/she fully understands its terms.

I consent to receive communication by text message specifically related to event participation

YesNo

Signature*

Name

First NameLast Name

Veteran Application