Veteran Adventures

Military Service Member *

First

Last

Date of Birth *

Are you the Service Member? *

Yes
No

Service Member's Home of Record *

Contact Information

Contact Method *

Email
Phone
Text

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Disability / VA Information

Has a VA disability rating been established? *

Yes
No
Pending

Has the Service Member been diagnosed with PTSD or TBI? *

Yes
No
Pending
Prefer not to say

Is the VA rating 30% or above?

Yes
No
Unknown

Getting to know you!

Briefly introduce yourself and tell us about yourself. The purpose of this is to help identify who you are, concerns you have, disabilities you are working through so that we may better serve you on our adventures. (Provide as much information you are comfortable with. All information provided is confidential and important. Important to you, your family, and us). *

Do you have any mobility issues or concerns of large crowds? *

Yes
No

Please explain below.

Family Status

Marital Status *

Number of children or legal dependents living in the home.