Registration

Warrior Bonfire Program Registration

Are you a Purple Heart Recipient?*

Yes

No

Please provide a copy of your DD214 or 215 showing a Purple Heart.

First Name*

Last Name*

Date of Birth*

Sex*

Email*

Phone*

Address*

City*

State*

Zip Code*

Military Branch*

Rank*

MOS*

Are you Active Duty?

Shirt Size

Are you Married?

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Email

My interest of activities include:

Hunting

Fishing

Skiing

Whitewater Rafting

Climbing and Reppelling

Sporting Events

Kayaking

Shooting (Adaptive)

Caving

Competitive Racing

Horseback Riding

Other Suggested Activity

If you feel comfortable sharing the details, please include the specifics of how, when and where you were wounded. (this information falls under the protection of the marketing release below.)*

Marketing Release: Participation requires the attendee to give permission to the Warrior Bonfire Program to include any and all photographs or video made during our events, to be used in any form of marketing that promotes the Warrior Bonfire Program. This includes the website, email marketing, social media, billboards, banners, and/or displays of any type. Title and property rights for these photographs and/or video will transfer to the Warrior Bonfire Program, and will be housed at the Warrior Bonfire Program offices and locations. Images or videos will never be shared, transferred or sold to any other intitiy that is not working on behalf to promote the Warrior Bonfire Program. Do you agree or disagree with the use of your picture for marketing and promotional items? Choose One

Agree

Disagree

MEDICAL PERMISSIONS I confirm that I have been cleared by my physician to fully take part in any/all of the activities presented by the Warrior Bonfire Program. I have been educated on all my medical limitations, medications, side effects and directions. My emergency contact is aware of my travel arrangements with the Warrior Bonfire Program and is readily available to assist in the case of an emergency. Have you been cleared by a physician to participate? Choose One * *

Agree

Disagree

The following questions are optional, however, will allow us to better assist you when traveling with WBP if there is an unforeseen emergency.

Known Allergies or Food Restrictions (food, medicine, insects, etc…)*

Current medical conditions (as it pertains to your level of activity, ability, or information needed if an emergency arises on our retreats)

List of Current Medications ( as it pertains to information needed in case of an emergency on our retreats)

Are you an amputee or in a wheelchair?

Yes

No

Have you been directed by your physician to NOT have an MRI?

Yes

No

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Primary Care Physician First Name

Primary Care Physician Last Name

Primary Care Physician Phone

Healthcare Facility

WAIVER AND MEDICAL RELEASE AGREEMENT As a participant in activities offered by and through the Warrior Bonfire Program, a non-profit 501(c)(3) organization, (herein ?WBP?), I understand that there are risks and dangers inherent in participating in activities offered by WBP as part of its program to provide recreational, cultural, and other events for United States military service members, veterans, and spouses of US service members or veterans. I also understand that in order to be allowed to participate in any of these activities, I must waive my rights to hold WBP liable for any personal injuries or property damages I may sustain while participating in such activities. Therefore, in consideration of WBP allowing me to participate in the activities, I hereby acknowledge and agree that I am assuming the risk of injury and/or damage to myself by reason of accident or occurrence of any kind whatsoever as a result of the programs and activities sponsored by WBP. I further agree that I shall never claim any damages against WBP, its officers, directors, employees, agents, volunteers or other persons or entities associated therewith as a result of any personal injuries or property damage, regardless of the fault or negligence of the WBP, its officers, directors, employees, agents, volunteers, or other related persons or entities. I further agree to indemnify WBP, it officers, directors employees, agents, volunteers, and other related persons or entities and hold them harmless from any and all claims, actions, damages, demands, liability, costs, fee, or other expenses in connection with the loss of life, personal injury, and/or property damage arising directly or indirectly from or out of any occurrence in connection with the activities and programs of the WBP. Said indemnification and hold harmless requirements shall include any and all costs and/or reasonable attorneys? fees incurred by WBP in connection with any claim by me, my heirs, representatives, executors, administrators, or other persons acting on my behalf or on behalf of my estate arising out of my participation in the WBP programs and activities. I further acknowledge that I have read and understood the terms of the Waiver and Release Agreement by checking the appropriate box option below. By choosing that you agree with with statements, you waive the right to proceed with any legal action against the Warrior Bonfire Program and all associated.

Agree

Disagree

Spaces are filled based on proximity to the event or our ability to find air transportation for you within our budget for that event. This registration will place your file on our waitlist. Applicant will receive emails periodically, offering travel opportunities. Priority is given to those on our waitlist. Once the veteran has traveled with WBP, they will be allowed to travel repeatedly but again priority is given to waitlist members first. Only WBP trip alumni are allowed to participate in WBP hunts unless they have been recommended by an existing WBP alumni member.

How did you hear about us?*

WBP Member Registration

Warrior Bonfire Program Registration