Veteran Application Form
Please click here to read all instructions before filling this form out!
Date of Birth:
PLEASE NOTE THAT OUR POLO SIZES RUN BIGGER THAN NORMAL*
MILITARY SERVICE HISTORY:
FOR VIETNAM VETERANS: Please upload a copy of your DD214 form, in either JPG, PNG, or PDF format, with the File Upload function below. If you have trouble doing so, please email your form to email@example.com - Thank you.
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)
DAILY ACTIVITIES: Please check the boxes that apply to you
In the past 3 months, have you needed help with any of these activities?
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?
MEDICAL CONDITIONS: Please place a checkmark next to the condition(s) that you
currently have or have had in the past 5 years