Date of Birth:
Phone Numbers:
PLEASE NOTE THAT OUR POLO SIZES RUN BIGGER THAN NORMAL*
MILITARY SERVICE HISTORY:
FOR KOREAN WAR VETERANS: Please answer the Korean Service Medal question below - Thank you.
FOR VIETNAM VETERANS: Please answer the Vietnam Service question below.
EMERGENCY CONTACTS: List two (2) people you would like us to contact in case of an emergency. Email would be great if they have one. (If available, please list at least one family member other than your spouse as a contact)
Phone Numbers:
Phone Numbers:
In the past 3 months, have you required the need for one or more of the following?
In the past 3 months, have you had difficulty or needed assistance with the following activities?