U.S.S.A.
United Special Sportsman Alliance
"A Outdoor Wish Granting Charitable organization for all ages"
2012 USSA-YOUTH RECIPENT APPLICATION
Name
Date of BirthAgeSex: MaleFemale
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?  YesNo
Parents/Guardians:
Mother's Name
Address
CityStateZip code
PhoneMobile
E-mail if Applicable:
Father's Name
Address
CityStateZip code
PhoneMobile
E-mail if Applicable:
Physician's Name
Office Address
CityStateZip code
Office PhoneMobile
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 life threatening illness of the applicant and his/her medically-documented limitations. (Note: all information will be kept in strict confidence between U.S.S.A 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/elk/hog/bear/duck/goose/pheasant/coon/fresh water fishing/saltwater fishing or any other outdoor sports related wish
2) Has the applicant ever participated in any form of hunting and or fishing?  YesNo
Has the applicant ever partaken in a FREE fishing or hunting trip donated by any one or any organization?  YesNo

If so whenand since their disability or illness was diagnosed, how many hunting and fishing trips did the applicant attend
3) Has the applicant ever had or now has a hunting licenseand or fishing license?
4) Has the applicant ever attended a hunter safety course? If so, does he or she hold a certificate?if so please attach a copy of the hunting safety certificate. [Note: firearm safety is an important part of a successful hunt.]
5) Does the applicant have a suitable firearm for his/her particular wish, or will a suitable firearm need to be provided?
6) If the applicant chooses a fishing dream, does he or her have suitable tackle; or would tackle have to be provided?
7) Will the applicant need wheelchair accessibility to blinds, boats etc.?
8) Can you afford any incidentals out of pocket cost such as fuel and motel?[We will try to keep all dream events within a 300 mile radius of Applicants' home. Our goal is to help keeps costs moderate and have funds available for more dream events.]
9) Can you afford taxidermyand or meat processing expenses?

Footnote: Many members of U.S.S.A also sponsor some of these incidental hunting and fishing expenses for those families with the greatest need.
NOTE: IF POSSIBLE PLEASE INCLUDE PICTURE(S) OF APPLICANT

IMPORTANT: After your wish has been granted, please remember to send a personal thank you (with picture if available) to your donor. A thank you is truly cherished by the generous people that help make these wishes come true.

AMERICANS WITH DISABILITY ACT 1990, United Special Sportsmen Alliance prohibits discrimination against disabled people and guarantees equality of opportunity for people with disability as well as terminally ill for hunting and or fishing adventures.


WAIVER OF LIABILITY United Special Sportsman Alliance is a non-profit organization seeking to grant wishes for disabled and critically-ill individuals seeking to participate in a major hunting or fishing expedition. To that end United Special Sportsman Alliance requires the execution of this comprehensive waiver as follows: The undersigned agree that he/she, along with his/her successors, heirs, and assigns to hold harmless and forever indemnify of the United Special Sportsman Alliance Corporation, its Board of Directors, agents, and Collaborators from liability associated with any death or injury resulting from, or in association with, or during the execution of the event as set forth and otherwise facilitated by United Special Sportsman Alliance. The undersigned also agree that he/she, along with his/her successors, heirs, and assigned to hold harmless and forever indemnify of the person or persons offering the hunt and or fishing trip, namely the Donor, 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 the Donor and United Special Sportsman Alliance. This instrument shall be applicable to any accident, injury, or event that occurs in 2012 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, guests, etc.) This agreement also gives United Special Sportsman Alliance the legal right to use any pictures or video/audio recording taken for advertisement (which includes magazine, newspaper, website, brochures, television broadcasts etc.) with our purpose only being to help encourage others to participate in enjoying the great outdoors. (NOTE: Donor listed in the the Waver of Liability is the one donating the outdoor adventures.)


THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAIVER 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
CityStateZip code
Phone
Signature
Parent(s) signature required if under 18 years old
State of)
County of)
SUBSCRIBED and SWORN before me thisday of2012Exp. Date

NOTARY PUBLIC (Please make sure this application is signed before a notary public. You can find a notary public at most banks free of charge.)

PLEASE NOTE: In the event that the recipient (he or she applying) is not able to attend a scheduled wish trip, please take the courtesy to notify us as soon as possible so we can select another recipient from the list to fill the opening. If we are not contacted or do not receive an applicable excuse for a last minute withdrawal, the recipient may no longer be eligible to remain on the wish granting list.

Mail original application to the following address:

United Special Sportsmen Alliance

N7864 Shotwell Lane | Pittsville | WI | 54466 | (715) (884-2256)
Fax: (715) (884-7388)

www.childswish.com                E Mail childswish@gmail.com

(800) (518-8019)

Copyright © 2012 by United Special Sportsmen Alliance Inc. (U.S.S.A) All rights reserved.