Families of the Fallen Retreat Application

 Application Number
  
 Which retreat date/location are you applying for?
    July 28-31 (Marineland, FL)    September 22-25 (Marineland, FL)   
 Applicant First Name
  
 Applicant Last Name
  
 Gender
    Female    Male    Different Identity    Prefer Not to Say   
 E-mail Address
  
 Cell Phone
  
 Home Address
  
 City
  
 State
  
 Zip Code
  
 Date of Birth (YYYY/MM/DD)
  
 What is your current relationship status?
    Married    Dating/Engaged    Divorced/Separated    Remarried    Other   
 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)
    Army    Navy    Marines    Air Force    National Guard    Army Reserve   
 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
    None    Posttraumatic Stress    Chronic Pain    Weight Gain    Physical Limitations    Diabetes    Traumatic Brain Injury    Amputation    Hypertension    Breathing Problems    Gastric Problems    Vaccine Related Illness    Addiction, Dependency or Compulsive Behaviors (e.g., alcohol, drugs, gambling)    Sleep Problems    History of Suicidal Thoughts or Attempts in the past 6 months (if checked, please briefly describe your current status and treatment/safety plan below)    History of abuse or domestic violence (if checked, please briefly describe your current status and treatment/safety plan below)    COPD    Major Depression    Seizures    Psychosis   
 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):
    Not currently in treatment or support group, but have been in the past    VA Hospital    Treatment or support group from a community provider    Vet Center    DoD Programs    Never Participated in a treatment of support group   
 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?
    Single Bed    Double Bed   
 Applicant T Shirt Size
     