Participant Registration Form

First Name

Last Name

City

State

Postal Code

Mobile Phone

Work Phone

Home Phone

Preferred Phone

Birth year

Please enter a 4 digit birth year

Gender

Ethnicity

Other Ethnicity

Status

Are you wounded, ill or injured

Are you a disabled veteran?

Were you referred to PHWFF by a certified healthcare provider?

First Name

Last Name

Emergency Contact Relationship

Mobile Phone

Work Phone

Home Phone

PHWFF Geographic Region

Program Name

Date of Entry into PHWFF

DD/MM/YR

How did you get connected to PHWFF?

Other

Referring Medical Facility & Location

Do you have a service dog?

Do you have any allergies or dietary restrictions?

Please list them here

If yes, please enter their information here:

First Name

Last Name

Caregiver relationship

Caregiver Phone #

Current fly fishing experience level

Current Fly tying experience level

Current fly rod building experience level

Current fly casting experience level

To better serve and accommodate you, 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

Please Describe

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

Additional Information

Date of entry into military service

MM/YYYY

Date of separation from military service

MM/YYYY

Current rank or rank at discharge

Rank grade

Marital Status

Highest Level of Education

Employment Status

Employer Name

Former Employer

Title

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	Space Force

World War II	Korea
Vietnam	Cold War
Gulf War	Pre or Post 9/11
Operation Iraqi Freedom	Post 9/11 Iraq
Post 9/11 Afghanistan	Other
N/A	Operation Enduring Freedom

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

Amputation	Anxiety	Blind or severe visual loss
Burns	Depression	Post-Traumatic Stress (PTS)
Spinal Cord Injury	Traumatic Brain Injury (TBI)	Tinnitus
Severe hearing loss	Severe back, neck or shoulder problems	Military Sexual Trauma (MST)
Other (fill in the blank)

Participant Registration Form

Participant Contact Info