Volunteer Registration Form

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Volunteer Contact Info

Please note, fields with a red * are required and all other fields are optional.

First Name

Last Name

Street

City

State

Postal Code

Country

Mobile Phone

Work Phone

Home Phone

Birth year

Please enter a 4 digit birth year

Are you between 13 and 17 years of age?

YesNo

Preferred Phone

Gender

Ethnicity

Please Indicate Ethnicity

Minor Section

Enter your birthdate:

mm/dd/yyyy

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Email Address:

Parent/Guardian Phone Number:

Military Service Related

Did you serve in the military?

Status

Are you wounded, ill, or injured?

Are you a disabled veteran?

Have you been or are you currently a PHWFF Participant?

Are you currently utilizing or enrolled in VA medical services?

Do you have a service dog?

Do you require a caregiver?

Caregiver Information

Please share your Caregiver's First Name

Please share your Caregiver's Last Name

Please share your relationship with Caregiver

Please share your Caregiver's Mobile Phone

Please share your Caregiver's Email Address

Please share your Caregiver's Other Phone

Please select all conditions that apply to you

Amputation	Severe Back, Neck, or Shoulder Problems	Anxiety
Severe Hearing Loss	Blind or Severe Vision Loss	Spinal Cord Injury
Burns	Tinnitus	Depression
Traumatic Brain Injury (TBI)	Military Sexual Trauma (MST)	Post-Traumatic Stress (PTS)
Other Conditions (Add below)

Other Conditions (not listed above)

Branch of Military Service

US Marine Corps	Marine Corps Reserve	US Army
US Army Reserves	Army National Guard	US Air Force
Air National Guard	US Navy	US Navy Reserve
Coast Guard

Deployments and conflicts served in:

World War II	Korea
Vietnam	Cold War
Gulf War	Post 9/11 Iraq
Post 9/11 Afghanistan	Other

Other deployments or conflicts

Emergency Contact Information

First Name

Last Name

Emergency Contact Relationship

Mobile Phone

Work Phone

Home Phone

PHWFF Related Information

How did you get connected to PHWFF?

Other

In addition to volunteering with PHWFF, do you serve in a volunteer leadership role (Program Lead, Assistant Program, Regional Coordinator, Deputy Regional Coordinator, Board of Trustees)?

Please select any roles that you currently hold.

Regional Coordinator	Program Lead
Deputy Regional Coordinator	Assistant Program Lead
Staff	Board of Trustees

Headquarters Information

Staff	Paid Employee
Board of Trustees	Committee Chair
Board Service Start Date MM/DD/YYYY	Task Force
Board Service End Date MM/DD/YYYY	Employee Start Date MM/DD/YYYY
Trustee	Founder's Circle
Task Force - Other

PHWFF Geographic Region

PHWFF Program Name

PHWFF Email Address

Birthdate

MM/DD/YYYY

Are you a registered volunteer with the VA Voluntary Service?

YesNo

What month did you begin volunteering with PHWFF?

What year did you begin volunteering with PHWFF?

Do you have any allergies or dietary restrictions?

Please list them here

What skills do you bring to the organization?

Accounting	Organizational Leadership	Videography	Social Media
Public Speaking	Record keeping	Cooking	Photography
Fundraising	Graphic design	IT	Fly Fishing Education
Safety Instructor	(CPR/First Aid)	Guide Services	Other

Other skills

Please provide your experience level in each of the below areas. No experience is necessary to volunteer with PHWFF.

Current fly fishing experience level

Current Fly tying experience level

Current fly rod building experience level

Current fly casting experience level

Please complete the optional information below:

Are you right or left-handed?

Which hand do you use to retrieve a fly line

Shirt Size

Shoe Size

Do you have trouble with any of the following?

Walking distancesRocky terrainSteep inclinesAltitudeOther (Please describe below)

Please Describe

Do you have any other information you would like to share that would be helpful in planning your volunteer work with PHWFF activities or outings?

Additional Information

Optional Information

This information is collected for statistical reasons only and is confidential. We encourage you to complete the optional information to help us report on the demographics of our volunteers.

Date of entry into service

MM/YYYY

Date of separation from service

MM/YYYY

Current Rank or Rank at discharge

Rank grade

Do you have any military awards you would like to tell PHWFF about?

Military Awards

Medal of Honor	Army Distinguished Service Cross
Navy Cross	Air Force Cross
Coast Guard Cross	Defense Distinguished Service Medal
Distinguished Service Medal (Army)	Navy Distinguished Service Medal
Air Force Distinguished Service Medal	Coast Guard Distinguished Service Medal
Silver Star	Defense Superior Service Medal
Legion of Merit	Distinguished Flying Cross
Soldier’s Medal	Navy and Marine Corps Medal
Airman’s Medal	Coast Guard Medal
Gold Lifesaving Medal (Coast Guard)	Bronze Star Medal
Purple Heart

What is your disability rating percentage?

0 to 100

Marital Status

Highest Level of Education

Employment Status

Employer Name

Former Employer

Title

Personal Bio

Although it is not required, we encourage you to share more about yourself by adding a personal bio and photo.

Personal bio

Volunteer Photo

Volunteer