Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (For day-of contact) *

(###)

###

####

Is your phone number a cellphone or landline? (Cellphone number day of communication)

Cellphone

Landline

Disabled? *

Yes

No

Does the Veteran use a wheelchair? *

Yes

No

Does the Veteran use a walker? *

Yes

No

Do you need assistance getting into a boat? *

Yes

No

Will a caregiver be accompanying you on the boat? *

We ask that caregivers are for medical NEEDS only, as space is limited.

Yes

No

Previous Vet Fishing Day Participant? *

Yes

No

Branch of Service *

Army

Marine Corps

Air Force

Navy

Coast Guard

Space Force

National Guard/Reserves

Name of Veteran Spouse/Significant Other (if attending only)

If your spouse or significant other is not attending the Auxiliary event, please leave blank!

First Name

Last Name