Register - Hampton Roads ASYMCA

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Disabled Veteran's Registration Information

Name*

First Last

Email*

Mobile Phone*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Registration Details

Select Your Adventure*

Number of People in Your Group*

Please include yourself in count of your group. Maximum number of people in your group is 3 and may include (1) caretaker and/or (1) paid guest.

Please enter a number from 1 to 3.

Individuals Included in Your Group*

Select all that apply.

Wounded Veteran

Caretaker

Guest

Guest Fee Acknowledgement

You are welcome to bring one guest (in addition to your caregiver if required) to enjoy the trip and all included activities for a non-refundable fee of $25 which will be used to directly support funding for this event. Please note caregivers are NOT considered additional guests and will not need to pay the additional fee. Please only select 'Yes' if you are bringing someone other than, or in addition to, your caregiver.

I understand

Who will be covering the guest fee?

I will be paying for my guest

My guest is paying for themselves

Liability Release Acknowledgement*

Each individual participant must sign release forms prior to boarding a boat. The release forms included in this registration apply to the person completing the form only. Your guest and/or caretaker will be emailed a link to a stand-alone release form upon completion of this form. Please follow up with your guest and/or caretaker to ensure they complete and submit their waiver and release. Your registration will not be complete until all participants have signed the releases.

I understand

Do you have a LOD statement or other official military or VA documentation indicating the injury was service-connected and sustained in the line of duty?*

Please note: This event is reserved for individuals who have sustained combat related injuries. By selecting 'Yes' you are acknowledging that you were issued an LOD statement or other documentation certifying your injury was service related.

YES

Do you require the use of any of the special equipment listed below for your injury?*

Wheelchair

Walker

Cane

Crutches

None

Other

Waiver & Release

You are required to complete the release forms to complete your registration. Please add your Waiver & Release using the button below. DO NOT complete a Waiver and Release for your caretaker or guest. Your guest and/or caretaker will receive an email with a link to add their own Waiver & Release.

Row ID	Your Name	This waiver is for	Actions

There are no Waivers & Releases.

Guest's Information

Guest's Name*

First Last

Guest's Email*

Your Guest is required to submit a seperate registration. A link to complete their registration will be sent to this email address.

Caregiver's Information

Caregiver's Name*

First Last

Caregiver's Email*

Your Caregiver is required to submit a seperate registration. A link to complete their registration will be sent to this email address.

Hearts for Heroes Registration

Disabled Veteran's Registration Information

Registration Details

Waiver & Release

Guest's Information

Caregiver's Information