c/o Leonard A. Livingston
P. O. Box 494
Ekalaka, Montana 59324
Phone: (406) 775-6276
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Beaver Creek Rendezvous c/o Leonard A. Livingston P. O. Box 494 Ekalaka, Montana 59324 Phone: (406) 775-6276 |
Name:_________________________________Social Security Number:____________________ Address:_________________________City:________________State:______Zip:___________ Home Phone Number:________________________Work Phone Number:_____________________ Place of Employment:___________________________Date of Birth:__________Age:______ Weight:__________Eye Color:___________Hair Color:__________Height:_______Sex:____ Jacket Size:______Companion Name:__________________________Relationship:_________ Medications:_____________________________________________________________________ Allergies:_______________________________________________________________________ Physical Abilities: Diagnosis and Description (include reason for your disabling condition and length of time in a wheelchair)____________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Do you participate in outdoor activities?________Please describe:________________ _________________________________________________________________________________ How often do you get outdoors?___________________________________________________ Do you consider yourself independent?_________Have you hunted before?____________ Game hunted:_____________________________________________________________________ When were you last hunting?______________________________________________________ Successful? Yes:____No:____Rifle/Caliber/Scope you use:__________________________ _________________________________________________________________________________ Will you require assistance to aim your rifle?___________________________________ Difficulties with vision?_____________Difficulties with coordination?____________ Do you need assistance to stand?________Do you tire easily?______________________ Difficulties with outdoor temperatures?__________________________________________ Special diet needs:______________________________________________________________ _________________________________________________________________________________ Do you need assistance with meals?_______________________________________________ Would you be interested in skinning your antelope or deer with assistance?_______ Do you utilize a wheelchair for independence?_____________Describe (including the approximate amount of time averaged per day? (25% 50% 75% 100%):_________________ _________________________________________________________________________________ What type of chair would you bring to the hunt? (pneumatic tire, manual, electric etc.)____________________________________________________________________________ Do you use a walker,cane or crutches for independence?___________________________ Describe any special needs:______________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Will you have a companion along for personal assistance outside of field activi- ties?____________________________________________________________________________ Do you have any reservations about being interviewed or photographed by the press? _________________________________________________________________________________ How did you learn about the BCR Hunt?____________________________________________ _________________________________________________________________________________ Reason for applying to participate in the BCR Hunt?______________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Two references who know you and your situation well: Name:___________________________Phone Number:____________________________________ Name:___________________________Phone Number:____________________________________ SIGNATURE:___________________________________DATE:____________