Moment Of Peace Adventures

Application

The primary goal of Moment of Peace Adventures is to give your child a Moment of Peace. If accepted, your child and at least one parent will be treated to an all-expenses paid hunting or fishing adventure! Each adventure is tailored to your child’s situation and abilities. Your adventure will also include pictures and videos taken during the adventure that will then be used to create a photo album and DVD so you can share your adventure with family and friends! Depending on the adventure you are interested in, hunting or fishing, a mount of your trophy as well as standard processing are included. The most important thing about your adventure is that our goal is to give your child and you a Moment of Peace! To try and forget about doctors, hospitals, and treatments. To make memories that will last a lifetime and new friends as you are welcomed into the MOPA Family!

Eligibility Requirements:

Child must be 18 or under at time of submission of the application.
Child must have or had a life-threatening illness or severe physical disability.
This application must be filled out by a parent or legal guardian.
MOPA Representatives must be able to work with and communicate with the child during the adventure. Safety of the child and MOPA reps is our top concern on the adventure! The adventure is to be a Moment of Peace for the child and parent/legal guardian on the adventure. If the activities will be too stressful for the child, it’s not a Moment of Peace. There are some children or illnesses, or disabilities that we may just not be equipped to handle. If denied, we will try to give references to other organizations.
An interview between MOPA representatives and the applying family will be conducted to determine eligibility.

Download Application Form

About the Youth:

Name of youth

Please enter the name of the youth.

Date of birth

Please enter the youth's date of birth.

Address

Please enter the youth's address.

City

Please enter the youth's city.

State

Please enter the youth's state.

Zip Code

Please enter the youth's zip code.

County

Please enter the youth's county.

Height

Please enter the youth's height.

Weight

Please enter the youth's weight.

T-Shirt Size

Please enter the youth's t-shirt size.

Sex:

Male

Female

Please select the sex of the youth.

Parent(s)/Guardian(s):

Parent/Guardian Name

Please enter the name of the Parent/Guardian.

Parent/Guardian Relationship

Please enter the relationship of the Parent/Guardian.

Parent/Guardian Email

Please enter the email of the Parent/Guardian.

Parent/Guardian Phone Number

Please enter the phone number of the Parent/Guardian.

Parent/Guardian Name

Parent/Guardian Relationship

Parent/Guardian Email

Parent/Guardian Phone Number

Medical Condition:

Primary Diagnosis

Treating Physician's Name

Treating Physician's Address

Treating Physician's Phone Number

Is there a medical reason why we need to act quickly?

Sibling(s):

Sibling Name

Sibling Relationship

Sibling Age

Sibling Name

Sibling Relationship

Sibling Age

Sibling Name

Sibling Relationship

Sibling Age

How did you hear about Moment Of Peace Adventures?

What type of adventure is the youth interested in?

Upload a Doctor's Form (PDF Only)

All applications are reviewed the second Wednesday of the month at our Officers/Board Meetings. If an application is received that is deemed an emergency ASAP adventure, the Board of Directors will begin reviewing the application immediately and not wait for the Officers/Board Meeting.