Adaptive Party Boat Fishing Tournament Application

1. Name of Fisherman

First Name

Last Name

2. Age of Fisherman

3. Parent/Guardian Name

First Name

Last Name

4. Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

5. Email Contact

6. Home Phone

(###)

###

####

7. Emergency Contact

First Name

Last Name

8. Emergency Contact Phone

(###)

###

####

9. Food Allergies

10. In order to provide a safe and properly supervised environment for our guests, We ask that guests have a level of independence that does not require direct one to one supervision.

Independent

Requires some supervision

11. Additional Information, Concerns or Medical Conditions (for example: seizures, etc.)

The Tommy Brull Foundation Inc. is a 501(c)(3) charity. Our mission is to raise money to benefit people and organizations dedicated to serving people with physical, mental, and emotional challenges in Nassau and Suffolk counties.