INDIANA MOUNTAIN MOVERS APPLICATION
ELIGIBILITY
In order for an applicant to be approved, they must meet the following requirements:
Must be 11-18 years old.
Permanently reside in or very near to Indiana.
Currently experiencing or has previously experienced a life-altering medical situation or diagnosis.
Must be able to complete basic self-care with little to no assistance.
Does not require a caregiver or regular special assistance.
This does not include assistance with medication or mobility.
The participant's permanent residence is located in or near the state Indiana:
*
Yes
No
If no, please explain:
*
The participant is 11-18 years of age:
*
Yes
No
If no, please explain:
*
The participant is experiencing or has previously experienced one or more of the following life altering medical situations or diagnoses:
*
Cancer or Other Illness
Physical Disability (Muscular Dystrophy, Loss of limb or function of a limb, Cerebral Palsy, etc.)
Loss of a Sibling or Parent (Due to Medical Situation)
Severe Accident
Rare Disorder or Diagnosis
Other
The participant can complete basic personal hygiene tasks such as showering, brushing their teeth, using the bathroom, etc. independently:
*
Yes
No
If no, please explain:
*
The participant does not require a caregiver or regular special assistance:
*
Yes
No
If no, please explain:
*
I understand that not every applicant will receive an opportunity with AO1 Foundation's Mountain Movers Program:
*
Yes
No
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INDIANA MOUNTAIN MOVERS APPLICATION
PROSPECTIVE CHILD INFORMATION
NAME:
*
First Name
Last Name
DATE OF BIRTH:
*
-
Month
-
Day
Year
Date
CURRENT AGE:
*
GENDER:
*
Male
Female
ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please explain the medical battle or victory the child has overcome or is currently battling in his/her life:
*
Please be as specific as possible
Does the child have any medical or psychological needs we should be aware of?
*
Yes
No
Please explain:
*
Does the child have any previous hunting, fishing, hiking/camping, or other outdoor experience?
*
Yes
No
Has the child obtained their Hunter's Safety Certification?
*
Yes
No
Unsure
Is the child comfortable participating in a trip without their parent or guardian? *Please note, limited options exist for children who are accompanied by a guardian
*
Yes
No
Unsure
What type of adventure would most interest this child?
Rows
Not Interested
Somewhat Interested
Unsure
Interested
Very Interested
Hiking / Camping
Fishing
Upland (Pheasants, Grouse, etc.)
Waterfowl (Ducks and Geese)
Turkey
Whitetail Deer
Mule Deer
Black Bear
If a different outdoor adventure is desired, please explain:
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INDIANA MOUNTAIN MOVERS APPLICATION
PARENT OR GUARDIAN INFORMATION
Are you the participant's parent or legal guardian?
*
Yes
No
NAME:
*
First Name
Last Name
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER:
*
-
Area Code
Phone Number
EMAIL:
*
example@example.com
SUBMIT
Should be Empty: