Nominator *
Please provide the information of the individual filling out this form:
First Name * ______________________________________________________
Last Name * ______________________________________________________
Address (no PO Boxes) *
Address _________________________________________________________
City _____________________________________________________________
State ____________________________________________________________
Zip Code _________________________________________________________
Country __________________________________________________________
Cell Phone * ________________________________________________________
Email * _____________________________________________________________
Relationship to Nominee * __________________________
Nominee *
Please provide information for the individual being nominated for a FYSH Foundation outing:
Age * _____________
First Name * ______________________________________________________
Last Name * ______________________________________________________
Address (no PO Boxes) *
Address _________________________________________________________
City _____________________________________________________________
State ____________________________________________________________
Zip Code _________________________________________________________
Country __________________________________________________________
Cell Phone * ________________________________________________________
Email * _____________________________________________________________
If possible, please have nominee fill out this section
Essays are the opportunity for you to differ yourself from others and shine. Be direct, descriptive, and creative. This is your time! Your Personal Statement is very important for us to better understand who you are and how we can help you.
Please write your Personal Statement in no less than 250 words and more than 650 words, letting us know WHY you would like to receive a day of fishing or an outdoor experience with the FYSH Foundation *
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What days are you available to fish or an outing? *
MEDICAL CONCERNS
Our outings can be physically tiring, even exhausting. The facility or activities may require nominee to manage uneven terrain, be at a high altitude, require hiking, climbing, running, swimming, lifting, stairs, and other strenuous activities depending on the activity. Your medical condition (physical fitness, recent or chronic injuries, allergies, physical or emotional limitations, etc.) and even the medications you take may be affected by the activities, the altitude, or the emotional challenges.
Do you have any medical conditions, allergies or concerns, or are you taking any medications that you believe could prevent you from being an effective participant that we need to know about in order to help you have the best day possible? *
Can you swim? *
I hereby grant permission to the FYSH Foundation to use photographs and/or video of the participant, including minors, named on this application in publications, news releases, online, and in other communications related to the mission of the FYSH Foundation.
Emergency Contact:
Relationship to you * ______________________________________________
First Name * ______________________________________________________
Last Name * ______________________________________________________
Address (no PO Boxes) *
Address _________________________________________________________
City _____________________________________________________________
State ____________________________________________________________
Zip Code _________________________________________________________
Country __________________________________________________________
Cell Phone * ________________________________________________________
Email * _____________________________________________________________
If you are under the age of 18 we must contact a parent or guardian for approval of participation:
Parent/Guardian
First Name * ______________________________________________________
Last Name * ______________________________________________________
Address (no PO Boxes) *
Address _________________________________________________________
City _____________________________________________________________
State ____________________________________________________________
Zip Code _________________________________________________________
Country __________________________________________________________
Cell Phone * ________________________________________________________
Email * _____________________________________________________________
By clicking Submit below, I hereby affirm that the statements made on this application are true. I understand that this is a non-paid volunteer position. If selected, I agree to act in the best interest of the FYSH Foundation. I understand that this personal information will be held confidential by the FYSH Foundation.
____ I agree with the statement above (initial) *
_________________________________________________________________________________
Signature & Date
Please email completed Nomination Application forms to: help@fyshfoundation.org
(all fields with asterisk are required. Incomplete application will not be considered.)