NWAFF WHEELCHAIR SCHOLARSHIP APPLICATION

Wheelchair scholarship Applicant Information

Full Name
Today's Date
Date of Birth
Gender	M F
Disability
Do you own a sport wheelchair?	Yes No
Phone
Cell Phone
Street Address
City
State
Zip
Email Address
Emergency Contact
Emergency Contact Relationship
Emergency Phone

Disclaimer

I understand that Northwest Arkansas Fencing Foundation officials reserve the right to request more information and verify (check) the information. I, also, understand that Northwest Arkansas Fencing Foundation is not responsible for injury or loss of property while participating in above scholarship activity. I do, hereby, release Northwest Arkansas Fencing Foundation, it's employees, sponsors & Board of Directors from any liability for any accident or injury.

Electronic Signature (Full Name)

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