Volunteer Registration Form

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 Volunteer Contact Info

Please note, fields with a red * are required and all other fields are optional.

First Name

MI

Last Name

Street

City

State

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau AE

Postal Code

Country

Please select... Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe

Email

Mobile Phone

Work Phone

Home Phone

Birth year

Please enter a 4 digit birth year

Are you between 13 and 17 years of age?

YesNo

Preferred Phone

Please select... Mobile Work Home

Gender

Please select... Male Female

Ethnicity

Please select... American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander Caucasian More than one ethnicity Other

Please Indicate Ethnicity

Minor Section

Enter your birthdate: 

mm/dd/yyyy

Parent/Guardian First Name: 

Parent/Guardian Last Name:

Parent/Guardian Email Address: 

Parent/Guardian Phone Number:

Military Service Related

Did you serve in the military?

Please select... Yes No

Status

Please select... Active Duty Reserve/Guard Veteran Retired

Are you wounded, ill, or injured?

Please select... Yes No

Are you a disabled veteran?

Please select... Yes No

Have you been or are you currently a PHWFF Participant?

Please select... Former Participant Active Participant None

Are you currently utilizing or enrolled in VA medical services?

Please select... Yes No

Do you have a service dog?

Please select... Yes No

Do you require a caregiver?

Please select... Yes No

Caregiver Information

Please share your Caregiver's First Name

Please share your Caregiver's Last Name

Please share your relationship with Caregiver

Please share your Caregiver's Mobile Phone

Please share your Caregiver's Email Address

Please share your Caregiver's Other Phone

Please select all conditions that apply to you

Amputation	Severe Back, Neck, or Shoulder Problems	Anxiety
Severe Hearing Loss	Blind or Severe Vision Loss	Spinal Cord Injury
Burns	Tinnitus	Depression
Traumatic Brain Injury (TBI)	Military Sexual Trauma (MST)	Post-Traumatic Stress (PTS)
Other Conditions (Add below)

Other Conditions (not listed above)

Branch of Military Service

US Air Force	USAF Reserves	Air National Guard
US Space Force	US Space Force Reserves	US Navy
US Navy Reserve	US Marine Corps	Marine Corps Reserve
Coast Guard	US Army	US Army Reserves
Army National Guard

Deployments and conflicts served in:

World War II	Korea
Vietnam	Cold War
Gulf War	Pre or Post 9/11
Operation Iraqi Freedom	Post 9/11 Iraq
Operation Enduring Freedom	Post 9/11 Afghanistan
Other

Other deployments or conflicts

Emergency Contact Information

First Name

Last Name

Emergency Contact Relationship

Email

Mobile Phone

Work Phone

Home Phone

PHWFF Related Information

How did you get connected to PHWFF?

Please select... Referred by friend or family member Referred by military health care provider PHWFF social media Referred by VA health care provider PHWFF website Fly Fishing Show Fly Fishing Shop Other

Other

In addition to volunteering with PHWFF, do you serve in a volunteer leadership role (Program Lead, Assistant Program, Regional Coordinator, Deputy Regional Coordinator, Board of Trustees)?

Please select... Yes No

Please select any roles that you currently hold. 

Regional Coordinator	Program Lead
Deputy Regional Coordinator	Assistant Program Lead
Staff	Board of Trustees

Headquarters Information

Staff Please select... Paid Employee Volunteer	Paid Employee Please select... Full-Time Part-Time Contract
Board of Trustees Please select... Task Force Board Chair Board Vice Chair President Secretary Treasurer Committee Chair Trustee Founder's Circle	Committee Chair Please select... Governance Committee Fundraising and Development Committee Program Committee Finance and Audit Committee Executive Committee
Board Service Start Date MM/DD/YYYY	Task Force Please select... Strategic Planning Task Force Other
Board Service End Date MM/DD/YYYY	Employee Start Date MM/DD/YYYY
Trustee Please select... Governance Committee Fundraising and Development Committee Program Committee Finance and Audit Committee Executive Committee	Founder's Circle Please select... Chair Secretary Memeber
Task Force - Other

PHWFF Geographic Region

Please select... Alabama Alaska Florida Headquarters Heartland Midwest National Capital New England New Jersey New York North Carolina Northwest Pennsylvania Rocky Mountain North Rocky Mountain South South Central Southeast Southwest Tennessee Valley Virginia West Virginia

PHWFF Program Name

Please select... Anchorage Fairbanks Wasilla Bay Pines Cape Coral Eglin Pensacola Pompano Beach Sarasota Space Coast Freedom Ranch for Heroes Oak Heart Lodge Central Nebraska Leavenworth - KS Lincoln, NE Little Rock Mountain Home Northwest Arkansas Omaha Springfield/Branson St. Louis - VAMC Topeka Tulsa Wichita Akron Ann Arbor Appleton Battle Creek Cleveland Columbus/Central Ohio Dayton Des Moines Evansville Indianapolis Minneapolis North Chicago Rocky River Sheffield Village OH St. Cloud Tomah Traverse City Bethesda Dover Frederick Ft. Belvoir Ft. Meade MD La Plata Quantico Washington DC Augusta - Maine Bangor Bedford Cape Cod Fall River Green Mountain Veterans - Burlington Leominster Lowell Machias Newington Northampton Northeast Passage Saugus White River Junction Jersey Shore Northeast NJ Northwestern NJ Raritan Valley South Jersey Fly Fishers Buffalo Castle Point Ft. Drum New City New York City Northport Oswego Port Jervis Syracuse Asheville Camp Lejeune Charlotte Crystal Coast Durham Fayetteville Greenville - NC Richlands (Camp LeJeune) Winston-Salem Bend Boise Coeur d' Alene Idaho Falls Joint Base Lewis McChord Kitsap/Olympic Peninsulas Mid - Willamette Valley Portland and Vancouver Seattle Spokane Walla Walla White City Altoona/Hollidaysburg Coatesville (Philadelphia) Erie Harrisburg East King of Prussia Pittsburgh West Bradford Wilkes-Barre Bismarck Bozeman Casper Great Falls Hamilton Rapid City Sheridan Sioux Falls - Eastern SD Albuquerque Colorado Alpine Colorado Springs Denver Four Corners Grand Junction Montrose - CO Ogden Salt Lake City San Luis Valley Water Valley Austin Conroe Dallas Fort Hood Georgetown Lufkin San Antonio San Marcos Texas Hill Country Atlanta Auburn Augusta - GA Biloxi Birmingham Blue Ridge Charleston - SC Greenville - NC Greenville - SC Huntsville Oakwood Chico Las Vegas Long Beach Martinez Redding San Diego - VA San Francisco Sepulveda Tucson Chattanooga Clarksville/Fort Campbell Johnson City Knoxville Louisville Memphis Murfreesboro Nashville Northeast Arkansas River City Charlottesville Fredericksburg Hampton Roads Hot Springs - VA Richmond Roanoke and New River Valleys Shenandoah Valley Southwest Virginia Tidewater Winchester Beckley Clarksburg Huntington Lewisburg Morgantown Parkersburg Wheeling

PHWFF Email Address

When did you begin volunteering with PHWFF?

MM/YYYY

Birthdate

MM/DD/YYYY

Are you a registered volunteer with the VA Voluntary Service?  

YesNo

Do you have any allergies or dietary restrictions?

Please select... Yes No

Please list them here

What skills do you bring to the organization?

Accounting	Organizational Leadership	Videography	Social Media
Public Speaking	Record keeping	Cooking	Photography
Fundraising	Graphic design	IT	Fly Fishing Education
Safety Instructor	(CPR/First Aid)	Guide Services	Other

Other skills

Please provide your experience level in each of the below areas. No experience is necessary to volunteer with PHWFF.

Current fly fishing experience level

Please select... None New to fly fishing Intermediate fly fisher Advanced fly fisher Expert fly fisher

Current Fly tying experience level

Please select... None New to fly tying Intermediate fly tyer Advanced fly tyer Expert fly tyer

Current fly rod building experience level

Please select... None New to rod building Intermediate rod builder Advanced rod builder Expert rod builder

Current fly casting experience level

Please select... None New to fly casting Intermediate fly caster Advanced fly caster Expert fly caster

Please complete the optional information below:

Are you right or left-handed?

Please select... Right Left Ambidextrous

Which hand do you use to retrieve a fly line

Please select... Right Left Don't Know

Shirt Size

Please select... XS S M L XL XXL XXXL

Shoe Size

Do you have trouble with any of the following?

Walking distancesRocky terrainSteep inclinesAltitudeOther (Please describe below)

Please Describe

Do you have any other information you would like to share that would be helpful in planning your volunteer work with PHWFF activities or outings?

Please select... Yes No

Additional Information

Optional Information

This information is collected for statistical reasons only and is confidential. We encourage you to complete the optional information to help us report on the demographics of our volunteers.

Date of entry into service

MM/YYYY

Date of separation from service

MM/YYYY

Current Rank or Rank at discharge

Please select... Enlisted Warrant Officer

Rank grade

Please select... E-1 E-2 E-3 E-4 E-5 E-6 E-7 E-8 E-9 W-1 W-2 W-3 W-4 W-5 O-1 O-2 O-3 O-4 O-5 O-6 O-7 O-8 O-9 O-10

Do you have any military awards you would like to tell PHWFF about?

Please select... YES NO

Military Awards

Medal of Honor	Army Distinguished Service Cross
Navy Cross	Air Force Cross
Coast Guard Cross	Defense Distinguished Service Medal
Distinguished Service Medal (Army)	Navy Distinguished Service Medal
Air Force Distinguished Service Medal	Coast Guard Distinguished Service Medal
Silver Star	Defense Superior Service Medal
Legion of Merit	Distinguished Flying Cross
Soldier’s Medal	Navy and Marine Corps Medal
Airman’s Medal	Coast Guard Medal
Gold Lifesaving Medal (Coast Guard)	Bronze Star Medal
Purple Heart

What is your disability rating percentage?

0 to 100

Marital Status

Please select... Divorced Married Separated Single Widowed

Highest Level of Education

Please select... High School Diploma or GED Associate Degree Bachelor Degree Graduate Level Degree Post-Graduate Level Degree

Employment Status

Please select... Unemployed Part Time Employed Full Time Employed Retired

Employer Name

Former Employer

Title

Personal Bio

Although it is not required, we encourage you to share more about yourself by adding a personal bio and photo.

Personal bio

Volunteer Photo

Volunteer