Southern Christian Sportsmens Devotional, INC.
www.go-scsd.com
Application for Dream Hunt/Fish
Applicants Information
Name ______________________________________
Date of Birth:___/___/_____ Age ___ Male Female
Illness: ___________________________________________
If critically ill, what is the window of opportunity to participate in his/her dream: ____________
Is this individual aware of the life-threatening condition? Yes No
Parents/Guardians:
Mothers Name: ______________________________________________________
Address: ____________________________________________________________
City: __________________ State: ______________________ Zip Code: _________
Phone: ________________________ Mobile: _____________________________
E-mail if Applicable: ___________________________________________________
Fathers Name ________________________________________________________
Address: ____________________________________________________________
City: __________________ State: ______________________ Zip Code: _________
Phone: ________________________ Mobile: _____________________________
E-mail if Applicable: ___________________________________________________
Physician’s Name: __________________________________________________
Office Address: _____________________________________________________
City: __________________ State: ______________________ Zip Code: _________
Office Phone: ________________________
E-mail if Applicable: ___________________________________________________
Treatment Facility/Hospital: ______________________________________________
Summary of your patient’s physical limitations:
_____________________________________________________________________
Special Needs or
Accommodations: ______________________________________________________
Have Applicant’s Physician attach a statement as to the sort of disability or terminal illness the
individual has and his/her medically-documented limitations. [Note: all information will be kept in
strict confidence between Southern Christian Sportsmens Devotioanl, Inc. and those
immediately involved in the event itself.]
General Family Related Questions:
1) What type of dream hunt or fishing trip does the Applicant want? ___________________
Deer/freshwater fishing/saltwater fishing/other _______________________
2) Has the applicant ever participated in any form of hunting and/or fishing? Yes No
Has the applicant ever partaken in a FREE hunting or fishing trip donated by anyone or any
organization? Yes No
If so when, __________ and since their disability or illness was diagnosed, how many hunting
and/or fishing trips did the applicant attend? __________
3) Has the applicant ever attended a hunter safety course? Yes No
If so, does he or she hold a certificate? Yes No
[Note: Firearm safety is an important part of a successful hunt and is required in most states.]
4) Does the applicant have a suitable firearm for his/her particular wish? Yes No
5) If the applicant chooses a fishing dream, does he or she have suitable tackle and rod and
reel?
Yes No
6) Will the applicant need wheelchair accessibility to blinds, boats, etc.? Yes No
7) Can you afford any incidentals our of pocket costs such as fuel or motel? Yes No
Southern Christian Sportsmens Devotioanl will try to keep all dream events with in a 250 mile
radius of
applicants’ home.
Our goal is to help keep costs moderate so we can have funds available for more dream events.
NOTE: IF POSSIBLE PLEASE INCLUDE PICTURE(S) OF APPLICANT
Any Additional Comments:
AMERICANS WITH DISABILITY ACT 1990, Southern Christian Sportsmen’s Devotional prohibits
discrimination against disabled people and guarantees equality of opportunity for people with
disabilities as well as the terminally ill to engage int hunting and/or fishing adventures.
WAIVER OF LIABILITY: Southern Christian Sportsmen’s Devotional, Inc. is a non-profit
organization seeking to grant wishes for people with a life threatening illness seeking to
participate in a major hunting or fishing expedition. To that end, Southern Christian Sportsmen’
s Devotional, Inc. requires the execution of this comprehensive waiver as follows: The
undersigned agrees that he/she, along with his/her successors, heirs, and assigns to hold
harmless and forever indemnify the Southern Christian Sportsmen’s Devotional, Inc., its Board
of Directors, Agents, and Collaborators from liability associated with any death resulting from, or
in association with, or during the execution of the event as set forth and otherwise facilitated by
Southern Christian Sportsmen’s Devotional, Inc. The undersigned also agrees that he/she
along with his/her successors, heirs, and assigns to hold harmless and forever indemnify the
person or persons offering the hunting or fishing trip, namely Southern Christian Sportsmen’s
Devotional, Inc., its agents and collaborators from any and all liability associated with any
injuries sustained in association with, or during the execution of the event as set forth and
otherwise facilitated by Southern Christian Sportsmen’s Devotional, Inc. This instrument shall
be applicable to any accident, injury, or event that occurs in 2009 or succeeding years. The
undersigned personally accepts all liability and responsibility for the actions of everyone
hunting or fishing with him or her (including minors, friends, associates, guest, etc.)
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAVIER OF
LIABILITY AND INDEMNITY AGREEMENT, and further states that no oral representations,
statements, or inducements apart from this agreement have been made.
Date __________________
Name _____________________________________
Address ______________________________________
City ____________________ State _____ Zip Code _________
Phone _________________________
Signature ___________________________________________
Parents (signature if under 18) __________________________________________
State of ___________
County _______________
SUBSCRIBED and SWORN before me this _____ day of ___________ 200_
________________________________ Exp. Date _________________________
NOTARY PUBLIC
[Please make sure this application is signed before notary public]
Southern Christian SPORTSMEN’S DEVOTIONAL, INC.
803 Shelter Pionte RD; Statesboro, GA 30458; (912) 764-5407; Cell (912) 682-3863
www.go-scsd.com E-mail cah_3@yahoo.com
www.go-scsd.com
Application for Dream Hunt/Fish
Applicants Information
Name ______________________________________
Date of Birth:___/___/_____ Age ___ Male Female
Illness: ___________________________________________
If critically ill, what is the window of opportunity to participate in his/her dream: ____________
Is this individual aware of the life-threatening condition? Yes No
Parents/Guardians:
Mothers Name: ______________________________________________________
Address: ____________________________________________________________
City: __________________ State: ______________________ Zip Code: _________
Phone: ________________________ Mobile: _____________________________
E-mail if Applicable: ___________________________________________________
Fathers Name ________________________________________________________
Address: ____________________________________________________________
City: __________________ State: ______________________ Zip Code: _________
Phone: ________________________ Mobile: _____________________________
E-mail if Applicable: ___________________________________________________
Physician’s Name: __________________________________________________
Office Address: _____________________________________________________
City: __________________ State: ______________________ Zip Code: _________
Office Phone: ________________________
E-mail if Applicable: ___________________________________________________
Treatment Facility/Hospital: ______________________________________________
Summary of your patient’s physical limitations:
_____________________________________________________________________
Special Needs or
Accommodations: ______________________________________________________
Have Applicant’s Physician attach a statement as to the sort of disability or terminal illness the
individual has and his/her medically-documented limitations. [Note: all information will be kept in
strict confidence between Southern Christian Sportsmens Devotioanl, Inc. and those
immediately involved in the event itself.]
General Family Related Questions:
1) What type of dream hunt or fishing trip does the Applicant want? ___________________
Deer/freshwater fishing/saltwater fishing/other _______________________
2) Has the applicant ever participated in any form of hunting and/or fishing? Yes No
Has the applicant ever partaken in a FREE hunting or fishing trip donated by anyone or any
organization? Yes No
If so when, __________ and since their disability or illness was diagnosed, how many hunting
and/or fishing trips did the applicant attend? __________
3) Has the applicant ever attended a hunter safety course? Yes No
If so, does he or she hold a certificate? Yes No
[Note: Firearm safety is an important part of a successful hunt and is required in most states.]
4) Does the applicant have a suitable firearm for his/her particular wish? Yes No
5) If the applicant chooses a fishing dream, does he or she have suitable tackle and rod and
reel?
Yes No
6) Will the applicant need wheelchair accessibility to blinds, boats, etc.? Yes No
7) Can you afford any incidentals our of pocket costs such as fuel or motel? Yes No
Southern Christian Sportsmens Devotioanl will try to keep all dream events with in a 250 mile
radius of
applicants’ home.
Our goal is to help keep costs moderate so we can have funds available for more dream events.
NOTE: IF POSSIBLE PLEASE INCLUDE PICTURE(S) OF APPLICANT
Any Additional Comments:
AMERICANS WITH DISABILITY ACT 1990, Southern Christian Sportsmen’s Devotional prohibits
discrimination against disabled people and guarantees equality of opportunity for people with
disabilities as well as the terminally ill to engage int hunting and/or fishing adventures.
WAIVER OF LIABILITY: Southern Christian Sportsmen’s Devotional, Inc. is a non-profit
organization seeking to grant wishes for people with a life threatening illness seeking to
participate in a major hunting or fishing expedition. To that end, Southern Christian Sportsmen’
s Devotional, Inc. requires the execution of this comprehensive waiver as follows: The
undersigned agrees that he/she, along with his/her successors, heirs, and assigns to hold
harmless and forever indemnify the Southern Christian Sportsmen’s Devotional, Inc., its Board
of Directors, Agents, and Collaborators from liability associated with any death resulting from, or
in association with, or during the execution of the event as set forth and otherwise facilitated by
Southern Christian Sportsmen’s Devotional, Inc. The undersigned also agrees that he/she
along with his/her successors, heirs, and assigns to hold harmless and forever indemnify the
person or persons offering the hunting or fishing trip, namely Southern Christian Sportsmen’s
Devotional, Inc., its agents and collaborators from any and all liability associated with any
injuries sustained in association with, or during the execution of the event as set forth and
otherwise facilitated by Southern Christian Sportsmen’s Devotional, Inc. This instrument shall
be applicable to any accident, injury, or event that occurs in 2009 or succeeding years. The
undersigned personally accepts all liability and responsibility for the actions of everyone
hunting or fishing with him or her (including minors, friends, associates, guest, etc.)
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAVIER OF
LIABILITY AND INDEMNITY AGREEMENT, and further states that no oral representations,
statements, or inducements apart from this agreement have been made.
Date __________________
Name _____________________________________
Address ______________________________________
City ____________________ State _____ Zip Code _________
Phone _________________________
Signature ___________________________________________
Parents (signature if under 18) __________________________________________
State of ___________
County _______________
SUBSCRIBED and SWORN before me this _____ day of ___________ 200_
________________________________ Exp. Date _________________________
NOTARY PUBLIC
[Please make sure this application is signed before notary public]
Southern Christian SPORTSMEN’S DEVOTIONAL, INC.
803 Shelter Pionte RD; Statesboro, GA 30458; (912) 764-5407; Cell (912) 682-3863
www.go-scsd.com E-mail cah_3@yahoo.com
