Veteran Application Veteran Application Form Please click here to read all instructions before filling this form out! Last name * First name * Middle name or Initial (If applicable) Nickname (what you would like to be called) Date of Birth: Month * Select One...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day * Year * Gender male female Weight Height Address * City * Zip Code * Phone Numbers: Home Cell Email (If Applicable) Polo Shirt Size (Small, Medium, Large, XL, XXL, XXXL) * PLEASE NOTE THAT OUR POLO SIZES RUN BIGGER THAN NORMAL* Please check all applicable items that might be a concern during the airport screening Pacemaker ICD Defibrillator Metal Implant (Hip, knee joints) Insulin pump and/or Insulin loading dispensing products Oxygen and / or respiratory‐ related equipment MILITARY SERVICE HISTORY: Which war(s) are you a Veteran of? * World War II (December 1941 - December 1946) Korea (June 1950 - January 1955) Vietnam War or Era (February 1961 - May 1975) Cold War (Jan 1947-June 1950 or Jan 1955 - May 1960) FOR KOREAN WAR VETERANS: Please answer the Korean Service Medal question below - Thank you. Did you receive a Korean Service Medal (KSM)? * Yes No FOR VIETNAM VETERANS: Please answer the Vietnam Service question below. Did you receive a Vietnam Service Medal/Ribbon (VSM/VSR)? * Yes No Branch of Service * Military Rank at Completion of Service * Hometown (from what city and state did you enter the service?) Where did you serve (Country/Countries)? * What was your job or assignment in the military? Activity during WWII (Theatre of Operation, unit, division, battalion, ship, plane, etc) Calendar Years of Service * Please enter the years that you served. For example, 1943-1955 Personal awards, medals, honors, and/or unit commendations 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) 1) Name * Relationship * Phone Numbers: Home Cell * Email: * 2) Name * Relationship * Phone Numbers: Home Cell * Email: * DAILY ACTIVITIES: Please check the boxes that apply to you In the past 3 months, have you needed help with any of these activities? Dressing * NEVER SOMETIMES ALWAYS Using the bathroom * NEVER SOMETIMES ALWAYS Eating * NEVER SOMETIMES ALWAYS Taking Medication * NEVER SOMETIMES ALWAYS Bathing/Showering * NEVER SOMETIMES ALWAYS In the past 3 months, have you required the need for one or more of the following? Cane * NEVER SOMETIMES ALWAYS Walker * NEVER SOMETIMES ALWAYS Wheelchair * NEVER SOMETIMES ALWAYS In the past 3 months, have you had difficulty or needed assistance with the following activities? Standing for 20 minutes * NEVER SOMETIMES ALWAYS Walking 3 blocks * NEVER SOMETIMES ALWAYS Climbing Steps (Stairs/Bus) * NEVER SOMETIMES ALWAYS Getting up from a chair * NEVER SOMETIMES ALWAYS Moving around the house * NEVER SOMETIMES ALWAYS Getting out of Bed * NEVER SOMETIMES ALWAYS Are you ABLE to climb/walk 4‐5 steps to get on/off the bus more than once? * Yes No Next Δ