Veteran Application

Veteran Application Form

Please click here to read all instructions before filling this form out!

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.
Did you receive a Korean Service Medal (KSM)? *
FOR VIETNAM VETERANS: Please answer the Vietnam Service Medal question below.
Did you receive a Vietnam Service Medal (VSM)? *
Please enter the years that you served. For example, 1943-1955
If awarded a DD214, input "See DD214" (and upload it above) to exclude writing it all out
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:

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?