Name:

Address:

City, State, Zip:

,

Phone:

Area Code: - Phone:

Email Address:

Choose a Program:

Choose One Bahama Bay Resort Victorian Resort Take Flight Farms

Dates that you would like to use the condo/resort: ex: March 6-10, 2010 (Resort stays are limited to 7 days; 4 weeks notice required for air flights)

Please Check Availability

Service:

Choose One Army Marine Corps Navy Air Force

Component:

Choose One Active Reserve National Guard Retired

Pay Grade:

Choose One E1 E2 E3 E4 E5 E6 E7 E8 E9 O1 02 03 04 05 06 WO CWO2 CWO3 CWO4

Marital Status: (Check one)

yes: no:

Number of Dependents:

Ages of Dependents: (Separate with commas)

Names of all family members attending:

Are the dependent children registered in DEERS?
(Please attach documentation below)

yes: no:

Will you require help with transportation?

yes: no:

Are you medically discharged for wounds or injuries sustained in combat operations?

yes: no:

Did your injuries, wounds, or the death of your loved one occur during OIF/OEF?

yes: no:

Please, briefly describe your injuries and if you require special services due to your injuries:

Do you or a member of your family require ADA compliant accomodations?

yes: no:

Have you been awarded the Purple Heart?

yes: no:

Have you participated in one of our programs in the past?

yes: no:

How did you hear about us?

You must submit written verification of your injury, how the injury was sustained, or a copy of your Purple Heart otherwise your application is considered incomplete and will not be processed. One of the following documents must accompany this application as evidence of your eligibility:

DD 214, DD 215, WD AGO 53-55, General Orders or DD 1300

Applications without the required documentation of eligibility will NOT be processed. For help, please contact Kate@woundedwarriorsfamilysupport.org

You may attach the required forms as a .pdf or .jpg file

File Attachment:

DEERS Documentaion: