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 *

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