Application

Called Beyond Adventure application form.

Called Beyond Adventure you are applying for

Applicant Information

Legal / Full Name *

Date of Birth *

Age *

Height

Weight

Sex

Male Female

Wheelchair Bound?

Yes No

Parent / Guardian Information

Parents Married?

Yes No

Father Name

Father's Address

Father's Phone

Father's Email

Mother Name

Mother's Address

Mother's Phone

Mother's Email

Hunt / Fish License / Tag Information

Has the participant completed hunter safety?

Yes No

State course was completed in

Does the participant have a current hunting license?

Yes No

In what state?

Does the participant have a current fishing license?

Yes No

In what state?

Medical / Physician Information

A CBA team member will email you a medical communication form to give to your physician so that CBA can obtain a medical reference. Please watch your email for that.

Physician Name

Treatment Facility / Hospital

Address

Phone

Fax

Summary of Physical Limitations

Special Needs or Accommodations

Medical Condition, including stage of condition if known

Referral Information

Please provide 3 referrals. One referral needs to be from a teacher or school personnel and another from a pastor, member of your community, or anyone else that works with your child regularly. Only one referral may be a family member. Please provide the Personal Referral Form to your referral and, upon completion, email it to info@calledbeyondadventures.org.

Referral 1 – Name, Address, Phone, Email, Relation

Referral 2 – Name, Address, Phone, Email, Relation

Referral 3 – Name, Address, Phone, Email, Relation

Additional Information

Please share a bit about the applicant family, interests, activities, favorite things, etc.

Participant T-Shirt Size

T-shirt sizes for additional family members participating (note number per size)

Does the applicant, or anyone in the family attending, have a criminal history?

Yes No

Please Explain

Please attach a picture of applicant for promotional use

Accepted file types: jpg, png. Max file size: 10 MB.

Signature (type full name)