Registration

Perry & Juniata County Veterans Trout Derby Registration 2019

* Indicates required field

Name *

First

Last

Phone Number *

Email (if avail.) *

Home Address (Street/Box#) *

Line # 2 (if needed) *

City *

State *

Zip *

Fishing Experience *

"T" Shirt Size: Select One *

Branch of Service *

Does the Veteran have a VA disability rating? *

Does the Veteran require a Care Giver to travel *

Is the Veteran ambulatory? *

To Register by Phone:

**Jim Broughton at (985) 285-4923, Bill Wilson at (717) 957-2465

Send It

** If the registered veteran is unable to attend the Event, please call the above phone(s) numbers so we can arrange a replacement for that slot.**