MNBW Application

Minnesota Broken Wing Connection

Pheasant Hunt Invitational Application
Your Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Email *
example@example.com
Your preferred method of contact: *

By phone By email
Your Birth Date *

Month Day Year
Your Gender

Male Female
About your disability
Do you have a disability that prevents or limits your ability to hunt upland game birds? *

Yes No
If yes, please briefly describe your disability (Diagnosis/Symptoms): *
For independence do you use (check all that apply): *

Walker Cane Crutches Wheelchair
Which type of wheelchair do you use:

Manual Electric
How much do you use the wheelchair?

25% 50% 100%
Can you be transferred with assistance from your wheelchair for hunting and transportation purposes?

Yes No
Do you have any vision problems? *

Yes No
Please briefly describe your vision problems: *
Do you require a fully handicap accessible bathroom or will a standard bathroom with a 32" door be serviceable for you? *

Handicap accessible only 32" door okay No special requirements
About your activities
Do you consider yourself independent to enjoy the outdoors? *

Yes No
How often do you get outdoors? *
What outdoor activities do you currently participate in? *
Have you hunted before? *

Yes No
Briefly describe your last hunting outing and when: *
Have you hunted upland game birds before? *

Yes No
When and where did you hunt upland game birds? *
Please provide two references of someone who knows you and your abilities:
Name of your first reference *

First Name Last Name
Phone Number
Email
example@example.com
Name of your second reference:

First Name Last Name
Phone Number
Email
example@example.com
Do you want to share any special reason for wanting to participate in our event? *

Yes No
If yes, please share your reason
How did you hear about us or our pheasent hunts?
Do you have any additional comments or concerns?
Thank you for your application! We will acknowledge receipt of your application via email.
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Minnesota Broken Wing Connection

About your disability

About your activities

Please provide two references of someone who knows you and your abilities: