Application Personal InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCĂ´te d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRĂ©unionSaint BarthĂ©lemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweĂ…land Islands Country Phone*Email* Date of Birth* Date Format: MM slash DD slash YYYY 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 Military/First Responder Affiliation*Active Duty MilitaryVeteranRetired (LOS) MilitaryMedically Retired (TDRL or PDRL) MilitaryDischargedGuard/ReservesReservesPeace/Police OfficerFire FighterEMS/EMT/ParamedicEmergency Room Medical StaffBranch of Service*Air ForceAir Force ReserveArmyArmy ReserveAir and Army National GuardCoast GuardCoast Guard ReserveMarine CorpsMarine Corps ReserveNavyNavy ReserveFirst ResponderRank*First ResponderE-1E-2E-3E-4E-5E-6E-7E-8E-9E-10O-1O-2O-3O-4O-5O-6O-7O-8O-9O-10W-1W-2W-3W-4W-5Type of DischargeHonorableOtherActive Service Begin Date Date Format: MM slash DD slash YYYY Active Service End Date Date Format: MM slash DD slash YYYY Which of our programs are you interested in participating in?Select all that apply Clinical Therapy Support Groups Equine Therapy Culinary Therapy Art Therapy Photography Art Mentorship Therapeutic Retreats Social Retreats Social Events Your Medical InformationDeploymentsPlease list the locations and dates of your deployment(s)Please note any dietary constraints for yourself/guestAre you service connected for any medical reason?YesNoService Connected Medical conditionPlease list condition(s) and percentages.Current SymptomsCheck all that apply Headaches Difficulty with Sleep Pain Dizziness Vision Difficulties Light Sensitivity Hearing Difficulties Amputee Balance Problems Memory Problems Concentration Problems Depression Anxiety PTSD TBI Brain Injury Suicidal Thoughts/Behavior Homicidal Thought/Behavior Dissociative episodes Seizures Burn Problem Making Decisions Difficulty Communicating Clearly Other Injury - Specify Injury comments/notesPlease 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?YesNoPlease ExplainOther Medical ConditionsOther Contact InformationNameIf still serving First Last Email PhoneEmail PhoneAre you enrolled in the Wounded Warrior Program?YesNoList POCSignature*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. Δ