Full-Time Wheelchair User Lottery Deer Hunt
January 10, 2015
U.S. Fish and Wildlife Service
Tensas River National Wildlife Refuge
ALL PORTIONS OF THIS APPLICATION MUST BE COMPLETED TO BE VALID
ALL APPLICANTS MUST PROVIDE A LOUISIANA CLASS I - PHYSICALLY CHALLENGED HUNTERS PERMIT
Name (print): ______
Address: ______City: ______State: ______
Phone: ( ) Date of Birth: ___/____/___ Email: ______
Emergency Contact Information:
Name: ______Address: ______
Home Phone: ______Cell Phone: ______Work Phone: ______
Please describe the nature of disability:
Type of wheelchair: Power chair _____ Manual chair _____
Additional Information:
I would like the following person to be my volunteer guide assistant.
Name: ______Address: ______
Home Phone: ______Cell Phone:______Email Address: ______
Disclaimer: Due to volunteer support basis, assistance for personal hygiene needs will not be provided. Applicants will be required to provide their own care attendant.
Applications must be received by close of business December 3, 2014.
All participants must sign below: (If under 17 a parent or legal guardian must also sign). The applicant, by signing below acknowledges this program involves some risk and he/she assumes responsibility for his/her actions and for any injury that may result from participation and also waives and releases all other participants, the host, sponsors, instructors, officials, and/or other parties involved in the event from all claims and/or damage/injury incurred in connection with this event. In addition, participant grants the sponsors, and co-sponsors the unconditional right to use the name, voice and photographic likeness of the person listed above, in regards to any of the publications and audio/video productions
Signature Date
Signature of Parent or Legal Guardian (if under 17) Date
Mail To: Tensas River National Wildlife Refuge or National Wild Turkey Federation
Jean Mikeal Shelley Chamberlain
Park Ranger 1534 Ardner Rd.
2312 Quebec Road Haughton, LA 71037
Tallulah, LA 71282 Phone: 318-617-9672 (cell)
Phone: 318-574-2664 ext. 103 Fax: 318-390-7777 (fax)
Fax: 318-574-1624 Email:
Email: