Minnesota Broken Wing Connection
Pheasant Hunt Invitational Application
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
Email
*
example@example.com
Your preferred method of contact:
*
By phone
By email
Your Birth Date
*
Please select a month
January
February
March
April
May
June
July
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September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
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2015
2014
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2012
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1925
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1922
1921
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Year
Your Gender
Male
Female
About your disability
Do you have a disability that prevents or limits your ability to hunt upland game birds?
*
Yes
No
If yes, please briefly describe your disability (Diagnosis/Symptoms):
*
For independence do you use (check all that apply):
*
Walker
Cane
Crutches
Wheelchair
Other
Which type of wheelchair do you use:
Manual
Electric
Other
How much do you use the wheelchair?
25%
50%
100%
Other
Can you be transferred with assistance from your wheelchair for hunting and transportation purposes?
Yes
No
Do you have any vision problems?
*
Yes
No
Please briefly describe your vision problems:
*
Do you require a fully handicap accessible bathroom or will a standard bathroom with a 32" door be serviceable for you?
*
Handicap accessible only
32" door okay
No special requirements
Other
About your activities
Do you consider yourself independent to enjoy the outdoors?
*
Yes
No
Other
How often do you get outdoors?
*
What outdoor activities do you currently participate in?
*
Have you hunted before?
*
Yes
No
Briefly describe your last hunting outing and when:
*
Have you hunted upland game birds before?
*
Yes
No
When and where did you hunt upland game birds?
*
Please provide two references of someone who knows you and your abilities:
Name of your first reference
*
First Name
Last Name
Phone Number
Email
example@example.com
Name of your second reference:
First Name
Last Name
Phone Number
Email
example@example.com
Do you want to share any special reason for wanting to participate in our event?
*
Yes
No
If yes, please share your reason
How did you hear about us or our pheasent hunts?
Do you have any additional comments or concerns?
Thank you for your application! We will acknowledge receipt of your application via email.
Submit
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