Youth Nomination Enrollment Application

This nomination form is intended to provide basic information concerning a youth, 18 years or younger, being
nominated for a Big Hearts under the Big Sky trip experience. As part of the evaluation and trip granting process,
additional clarifying information or follow-up descriptions may be requested in addition to that being requested on this
form.

Download Pdf : Youth Nomination Enrollment Application

Section 1: Basic Nominee Information
Child’s Name of Nominee(s):
Nickname
Address
City
Zip
Phone
Age
Gender
- Man
- Woman
Email*
payment
Section 2: Individual/Organization Making the Nomination
Organization's Name
Contact Name
Address
City
Zip
Email
Phone
Please describe the nature of the life-threatening illness the child has been diagnosed with.*
Please describe the medical or physical challenges faced by the nominee that affect their safety, mobility or ability to participate in the requested trip experience if granted?*
Does the nominating Individual/Organization have the capacity to offer any financial support for this trip? If so, please describe.*
Has the Nominee received a donated adventure experience in the last three years; if so, please list them below.*
Section 3: Desired Experience
What type of Montana-based outdoors adventure experience is desired/requested (e.g. fishing, hunting, camping, backcountry pack trip, other)?*
Big Hearts under the Big Sky emphasizes service to families to strengthen and restore through shared experience the benefits of a trip.*
Please list the family members by name, relation, gender and age that would likely attend if the trip is granted.*
What physical challenges do any of the family members face and that should be considered if this trip were granted?*
We try and accommodate ALL the family members in some form of the trip. On hunting trips there can be only one hunter, but when fishing, camping horseback riding a few family members may be included. What activities would the attending family members like to enjoy as part of the Big Hearts trip experience?*
Section 4: Nominee Qualifications
Big Hearts under the Big Sky was established to provide therapeutic outdoor experiences to those who have provided extra-ordinary service to our country and to do so in a way that allows the immediate family to enjoy and share in the experience as fully possible. To qualify for the Big Hearts program, the child must be between 6 and 18 years of age at the time of nominatioin and must be a resident of the United States and must be diagnosed with a life-threatening illness. As part of the nomination review process, it may be asked to have a letter from the child’s physician affirming their fitness and ability to participate in the requested trip experience.
Why is this nominee a good candidate for a Big Hearts adventure trip experience?*
In what ways will the nominee’s family benefit from the experience?*
Will you be able to provide a letter from the child’s Physician that will address the fitness for the child to participate in the granted activity?*

Youth Nomination Enrollment Application

Section 1: Basic Nominee Information

Section 2: Individual/Organization Making the Nomination

Section 3: Desired Experience

Section 4: Nominee Qualifications

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