Saturday, November 15th 9:00 AM - 4:00PM
Glen Elder Area Office, 2131 180 Rd. Glen Elder, KS 67446

If you are a parent or guardian registering your youth, please complete this registration form for each participant.

For questions, contact Mike Nyhoff (785) 545-5285

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1. First Name

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2. Last Name

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3. Phone number of participant OR parent/guardian

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4. Email of participant OR parent/guardian

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5. Current zip code of where you live

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6. Participant Date of Birth (MM/DD/YYY)

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7. Kansas Dept. of Wildlife and Parks ID Number (found on any KDWP-issued license can be looked up in your account at https://gooutdoorskansas.com/ or in the GoOutdoorsKS app). If you do not have a KDWP #, write "None"

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8. Emergency Contact

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9. Do you consider yourself any of the following.. select all that apply.

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10. How much did the following influence your decision to participate in this course?

  Not Influential Slightly Influential Moderately Influential Very Influential Extremely Influential
Learning a new life skill
Learning how to harvest local, sustainable foods
Building confidence in a previously acquired skill
Wanting to feel more connected with nature
Interested in sharing knowledge/passion with others
Location of the course
I knew someone taking the course
I knew one of the instructors
Someone encouraged me to take the course

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11. Will you be bringing your own shotgun for this event, or borrowing one?

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12. Please select the phrase below that best describes your past experience with shotguns.

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13. Will you be attending with a hunting mentor, or do you need a hunting mentor to be provided for you?

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14. Please select the phrase below that best describes your past pheasant hunting experience.

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15. Which of the following statements most accurately reflects how you feel about your pheasant hunting skills and abilities? Please select one

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16. Which of the following statements most accurately reflects how you feel about your identity as a pheasant hunter?

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17. I, the undersigned, understand that the supervisors, sponsors, staff, and volunteers of the Kansas Department of Wildlife and Parks, and of the event facility, are not responsible in case of injury or illness. I further understand that should a serious injury or illness occur, I hereby grant my permission and consent for emergency medical or surgical care to be given, as determined by a licensed physician. I specifically agree to indemnify and hold the Kansas Department of Wildlife and Parks and the event facility harmless as to any claim for damages for an accident or injury of any kind resulting from the participation in activities associated with KDWP events. I understand that KDWP does not warrant the condition of any equipment used by me to facilitate this the activities at this event. I also acknowledge that photography may be used at this event, and I give KDWP permission to take and use any photo or image of me for advertising or educational purposes. ENTER YOUR FULL NAME BELOW.

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