Application Number

Which retreat date/location are you applying for? **MUST BE AVAILABLE FOR ENTIRE DATES & TIMES LISTED -Cannot attend partial dates**

Applicant First Name

Applicant Last Name

Gender

E-mail Address *WITHIN 5 DAYS OF SUBMITTING THIS APPLICATION YOU WILL RECEIVE AN EMAIL FROM ASHLEY@GRATITUDEAMERICA.ORG   Check your SPAM/JUNK folder on day 5 after submission and search your email for that address if you do not see an email.

Cell Phone

Home Address

City

State

Zip Code

Date of Birth (YYYY/MM/DD)

What is your current relationship status?

What is your role/relationship with your Gold Star Service Member/Veteran?

Branch of Gold Star Veterans Service (Note: You may select more than one answer below)

Approximate Date of Gold Star Veteran's Passing (YYYY/MM/DD)

How many years did you know your Gold Star Veteran?

Please select any of the following health concerns that you have

Please provide any additional information about the health concerns you described above:

Please describe any physical limitations you have and any assistance/accommodations you will need during the retreat

Do you have any food allergies?

Do you have a service canine?

Are you currently participating in any of the following treatment or support groups (select all that apply):

Have you attended any previous retreats for service members/families? (describe)

What do you hope to gain from participating in this retreat?

Do you have a hotel room preference?

Applicant T Shirt Size

WITHIN 5 DAYS OF SUBMITTING THIS APPLICATION YOU WILL RECEIVE AN EMAIL FROM ASHLEY@GRATITUDEAMERICA.ORG   Check your SPAM/JUNK folder on day 5 after submission and search your email for that address if you do not see an email. If you do not see our email anywhere in your boxes or folders, your application did not successfully submit - please re submit.  Have you read this message?

Retreat is for adults only & childcare isn't provided. Hotel, meals, & activities are provided, we CANNOT assist with transportation. Does this work for you?  ** If you select NO, we will NOT contact you about your application **

We cannot provide or assist with Transportation/Travel. Does this work for you?