Application | The Pink Berets

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Date of Birth*

What category best describes your race? (one or more categories may be marked)

Optional - non-identifiable demographic statistics are often requested on grant applications for retreat funding.

American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Some other race
Declined
Unavailable/Unknown

Branch of Service*

Rank*

Military Service*

Type of Discharge

Active Service Begin Date

Active Service End Date

Your Medical Information

Deployments

Please list the locations and dates of your deployment(s)

Please note any dietary constraints for yourself/guest

Are you service connected for any medical reason?

Yes
No

Service Connected Medical condition

Please list condition(s) and percentages.

Current Symptoms

Check all that apply

Injury comments/notes

Please include any details about the injuries you checked above that you think would be helpful for our program manager to know.

Do you have a history of substance abuse?

Yes
No

Please Explain

Other Medical Conditions

Other Contact Information

Name

If still serving

First Last

Email

Phone

Email

Phone

Are you enrolled in the Wounded Warrior Program?

Yes
No

List POC

Signature*

I certify that my answers are true and complete to the best of my knowledge. By typing your full name, you are agreeing to digitally sign this retreat application.