GRANT A HUNT APPLICATION

QUALIFICATION CRITERIA

21 YEARS OLD OR YOUNGER.
U.S. OR CANADIAN CITIZEN.
SUFFERING FROM A DISABILITY OR LIFE THREATENING ILLNSS.
MEDICAL CERTIFICATION FROM PHYSICIAN APPROVING ACTIVITY.
NO PREVIOUS OUTDOOR GRANTS.
A PARENT OR LEGAL GUARDIAN MUST ACCOMPANY THE CHILD.
CHILD MUST HAVE A HUNTER SAFETY CERTIFICATE.
ALL FIELDS MUST BE COMPLETED.
BLANK FIELDS WILL BE CONSIDERED AN INCOMPLETE APPLICATION.
ALL INCOMPLETE APPLICATIONS WILL BE DECLINED.

Information about the child

DATE OF APPLICATION _______/________/________

NAME_________________________NICK NAME_______________________

BIRTH DATE____/____/____Age____Gender______Height_____Weight_____

CHILDS SOCIAL SECURITY NUMBER _______________________________

Contact Information

PERMANENT HOME ADDRESS ____________________________________

CITY______________________STATE or PROVINCE___________________

ZIP or POSTAL CODE____________PHONE NUMBER__________________

DOES THE CHILD ATTEND SCHOOL? _______YES _______NO

IF YES, WHAT GRADE IS HE/SHE IN NOW? __________________________

NAME OF PARENT OR LEGAL GUARDIAN ___________________________

IF PARENTS ARE DIVORCED OR SEPARATED, WHICH PARENT HAS LEGAL CUSTODY____________________________________________

IF THE CHILD IS NOT IN THE CUSTODY OF THE PARENT, EXPLAIN THE RELATIONSHIP WITH THE GUARDIAN_______________________________

_______________________________________________________________

IS THERE ANOTHER CONTACT PERSON WHEN THE PARENTS OR GUARDIANS CANNOT BE REACHED? ______________________________

IF YES, WHO?__________________________________________________

THIS CONTACT'S TELEPHONE NUMBER IS___________________________

Information

IF THE CHILD HAS ANY SIBLINGS LIVING IN THE HOUSEHOLD, PLEASE PROVIDE THEIR NAMES AND AGES.

NAME__________________________________________AGE____________

DESCRIBE THE NATURE THE PARENT'S (GUARDIAN'S) OCCUPATIONS

_______________________________________________________________

LIST ALL ACTIVITIES THE CHILD PARTICIPATES IN ___________________

_______________________________________________________________

DESCRIBE WHY A GROUP LIKE GRANT A HUNT WOULD BE IMPORTANT TO THE CHILD.

_______________________________________________________________

HAS THIS CHILD EVER BEEN GRANTED A WISH FROM ANY

OTHER ORGANIZATION? _________YES _________NO

IF YES, EXPLAIN________________________________________________

_______________________________________________________________

HAS ANYONE EVER APPLIED FOR A SIMILAR GRANT ON BEHALF OF THIS CHILD, BUT NOT BEEN APPROVED? ___________________________

IF YES, EXPLAIN________________________________________________

______________________________________________________________

IS THERE A REASONABLE EXPECTATION THAT THIS CHILD COULD RECEIVE A SIMILAR GRANT IN THE FUTURE, FROM APPLICATIONS ALREADY SUBMITTED?____________

IF YES, EXPLAIN________________________________________________

_______________________________________________________________

WOULD YO BE FINANCIALLY ABLE TO TAKE THE SELECTED HUNTING

OR FISHING TRIP OFFERED BY GRANT A HUNT, WITHOUT THIS

ORGANIZATION GRANTING IT TO YOU? _______YES ________NO

IF YES, EXPLAIN________________________________________________

_______________________________________________________________

THE CHILD IS CURRENTLY SUFFERING FROM? ______________________

_______________________________________________________________

THE CHILD HAS THE FOLLOWING PHYSICAL LIMITATIONS OR SPECIAL NEEDS THAT MUST BE ACCOMMODATED DURING AND OUTDOOR ADVENTURE. ___________________________________________________

_______________________________________________________________

HAS THE CHILD EVER HUNTED OR FISHED BEFORE? _________________

_______________________________________________________________

PLEASE INCLUDE A PHOTO COPY OF THE CHILDS HUNTER SAFETY CERTIFICATE.

Medical Verification

THE CHILD'S ATTENDING PHYSICIAN IS_____________________________

ADDRESS______________________________________________________

CITY________________________STATE or PROVINCE_________________

ZIP or POSTAL CODE________________PHONE______________________

FAX______________________EMAIL________________________________

MAY WE CONTACT THE ATTENDING PHYSICIAN FOR MEDICAL VERIFICATION? ______YES ______NO

If yes, please sign the following release: I have granted GRANT A HUNT permission to contact my child's attending physician regarding the health status of my child and hereby grant permission for the physician to release the requested information to GRANT A HUNT. I understand that GRANT A HUNT will keep all information received under strict confidentiality.

______________________________________ _______________________

Parent or guardian Signature Date

Treatments

IS THE CHILD CURRENTLY UNDERGOING ANY REGULARLY SCHEDULED TREATMENTS? ______________________

IF YES, EXPLAIN ________________________________________________

_______________________________________________________________

Social Worker or Child Life Specialist (if any)

NAME_______________________CLINIC or HOSPITAL_________________

ADDRESS______________________________________________________

CITY_________________________STATE or PROVINCE________________

ZIP or POSTAL CODE__________________PHONE____________________

FAX_______________________EMAIL_______________________________

OF THE TRIPS CURRENTLY BEING OFFERED PLEASE SELECT,

IN THE ORDER OF IMPORTANCE, THE 3 YOU DESIRE THE MOST.

1. ____________________________________________________________

2. ____________________________________________________________

3. ____________________________________________________________

IF THERE IS A DIFFERENT TYPE OF HUNTING OR FISHING TRIP YOU WOULD LIKE TO EXPERIENCE, OTHER THAN THE TRIPS CURRENTLY OFFERED BY GRANT A HUNT, PLEASE TELL US ABOUT IT. WHILE WE CANNOT PROMISE WE WILL BE ABLE TO GRANT THAT TRIP TO YOU, WE WILL USE OUR RESOURCES TO TRY.

PLEASE EXPLAIN WHAT YOU WOULD LIKE, IF IT CURRENTLY ISN'T BEING OFFERED BY GRANT-A-HUNT.

_______________________________________________________________

WAIVER OF LIABILITY

IF THE CHILD IS APPROVED FOR A GRANT A HUNT OUTDOOR ADVENTURE, WILL THE PARENT OR GUARDIAN BE WILLING TO SIGN A COMPLETE WAVIER OF LIABILITY? ________YES ________NO

INFORMATION ABOUT THE PERSON COMPLETING THIS FORM.

I AM

_____THE CHILD'S PARENT OR LEGAL GUARDIAN

_____A CONCERNED FRIEND OR RELATIVE

_____THE CHILD'S SOCIAL WORKER OR CHILD LIFE SPECIALIST

_____THE CHILD

_____THE CHILD'S ATTENDING PHYSICIAN OR OTHER HEALTHCARE PROFESSIONAL.

MY NAME IS (if different from Parent or Guardian)_______________________

I CAN BE CONTACTE AT (if different from above)_______________________

ADDITONAL INFORMATION OR COMMENTS: ________________________

______________________________________________________________

PLEASE RETURN TO;

GRANT A HUNT

W204 N5925 LANNON ROAD

MENOMONEE FALLS, WISCONSIN

53051