Application Form

Please print this, fill it out and mail it to:   Pine Grove Lodge

823 Ridge Rd.

Pleasant Ridge, ME 04920

Name______________________________    

Address____________________________

__________________________________

Phone________________________

To be properly prepared and to plan a trip for you and your family, we need some info about you.  We have to organize different groups and trips according to disabilities, physical needs, and time of year. 

What event are you a victim to?___________________________________________________________

__________________________________________________________________________________

Do you have physical disabilities and any special needs?__________________________________________

___________________________________________________________________________________

What are your outdoor interests? What would you like to do on your trip to Pine Grove Lodge in Maine? __________________________________________________________

___________________________________________________________________________________

How many people are you requesting to bring with you?_________________

Why do you think you and your family would enjoy coming to our lodge in Maine?________________________

___________________________________________________________________________________

What do you hope to gain from the experience?_________________________________________________

____________________________________________________________________________________

We draw 1 recipient per month, but we also try to match desired trips with the corresponding time of year. If you're drawn during a time of year that does correspond with your desired trip, we will put your application back in for another drawing.

Any questions, please all Bob or Andrea   207-672-4011       or email info@pinegroveprogram.com