EmailMe Form - Potomac Highlands Wounded Warrior Outreach Events

Name of Veteran: *

First MI Last

Date of Birth *

DD / MM / YYYY

Do you have a VA-Rated Disability? *

Yes

No

Attach VA Declination Letter (if applicable)

IF yes: What is the estimated percentage of your VA-Rated Disability?

Military Service Branch: *

Rank:

Dates of Service: *

Type of Discharge: *

Wounded / Injured / or Disabled? *

Yes

No

Short Description:

Purple Heart Recipient? *

Yes

No

Purple Heart Recipient: Please upload a digital copy of your DD-214 or DD-215 form

Phone *

### - ### - ####

Email *

P.O. Mailing Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Any Physical Restriction/Handicaps that would require special treatment?

Service dog required? *

Yes

No

Service Dog needs to be Registered / Certified Service Dog.

Are you able to participate in Hunting / Fly Fishing Events? *

Yes

No

Do you have a West Virginia Hunting/Fishing License? *

Yes

No

Are you required to have a “Caregiver”? (Name, Relationship):

T-Shirt Size: *

What event would you like to attend: *

Event Reference Number *

Please enter the number of only one event. The reference number for all events can be found on the description for this event on our website.

Additional Comments

West Virginia State Law requires the once-per-lifetime completion of a certified hunting safety class for anyone wishing to participate in such an event who was born after 1975. To participate in any hunting-related event by Potomac Highlands Wounded Warrior Outreach, West Virginia citizens born after 1975 must comply with this requirement. Please check that you understand that this is a West Virginia state requirement. *

I Understand