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Personal Information

First Name(Required)

Last Name(Required)

Nickname

How would you like to be addressed?

Gender(Required)

Date of Birth(Required)

Weight (lbs)

Address

Street Address(Required)

City(Required)

State(Required)

Zip(Required)

Additional Information

Primary Phone(Required)

Email Address(Required)

Service Information

Branch of Service(Required)

Status of Service(Required)

Please specify

Theater of Operation(Required)

Please hold the CTRL button to select more than one theater

Please specify

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Theater of Operation

Rank(Required)

Date Honored with Purple Heart(Required)

Injury Information

Supplying your injury information will allow us to have the proper equipment, trained personnel and support systems in place for your adventure.

Are you an Amputee?(Required)

Are you wheelchair bound?(Required)

Please select an injury category(Required)

Please provide a short description of your injuries

Event Preferences

Wounded Warriors In Action offers a variety of adventures for sportsmen and women. From fishing trophy Bass to hunting the elusive whitetail deer, you will be sure to find an adventure worth taking. To learn more about the different events we offer click here .

Please indicate in order of your preference the type of activity you are most interested in.

Please select an option for all five choices, even if you repeat the same option in multiple boxes. You will only be contacted regarding the events you indicate interest in. If you are open to all opportunities, please select “No Preference” for all five choices.

1st Choice

2nd Choice

3rd Choice

4th Choice

5th Choice

Do you have a Hunter Certificate?(Required)

I HAVE a Hunter Safety Certificate

I do NOT have a Hunter Safety Certificate

A hunter safety certificate may be required for some events.

Certification Number

State of Issue

Date of Issue

Preferred Departure Airfield(Required)

Alternate Departure Airfield

Do you have a current passport?(Required)

Yes

Expiration Date

Emergency Contact Information

Please fill in your Emergency contact information.

Name(Required)

Phone(Required)

Emergency Contact Email

Relationship(Required)

Caregiver Information

Do you desire or need to have a caregiver accompany you during your event?(Required)

Yes

Please note that not all events are conducive to having an accompanying caregiver

Caregiver Name

Caregiver Phone

Caregiver Email

Caregiver Relationship

Caregiver Notes

Do you desire or need to have a service/companion dog accompany you during your event?(Required)

Yes

Please note that not all events are conducive to service dogs.

Dog Breed

Dog Name

Is the dog certified?

Yes

Discovery Information

How did you hear about us?

Please specify

Are you interested in supporting WWIA at fundraising and awareness activities in your area such as the Combined Federal Campaign (CFC) and our annual WWIA Sweepstakes Drive?(Required)

Yes

Unknown