Program application

Please Fill Out Our Application:

This Application is Due By July 1st For Our August 18th-August 25th Female Veteran Pilot Program.

Name: *

First

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

Email: *

Birthdate *

Height: *

Weight: *

Marital Status: *

Do 'You Have Children? *

List or Describe: MOS, AFSC, or NEC: *

Please Provide VA Rating and Describe Injury: *

Please List or Describe: Combat Service OEF, OIF, or Other *

Provide Type of Discharge and Rank: E/O/W *

List Interests and Activitites: *

Are These Activities Limited By Your Physical or Mental State? If so, how? *

What Stress Relieving Outlets Do You Have and How Often Do You Engage in Them? *

Please List Physical, Mental or Allergic Concerns: *

Please Tell Us About Your Family:

What Challenges, If Any, Do You Find in Connecting With Your Family and/or General Support Network? *

Describe Your Biggest Obstacles That You Struggle To Overcome: *

What Do You Hope to Gain From The Serenity Ranch? *

What Ways Have You Tried To Achieve These Goals Before Looking Into The Serenity Ranch? *

Please List Any Other Veterans Programs Or Trips You Have Participated In: *

What Are The Benefits You Have Gained From Any Prior Treatment? *

Please Describe Your Current Pattern of Using Alcohol, Prescription Medicine and/or Street Drugs: *

How Much of a Role Does Your Pattern of Use Play In Your Daily Life Right Now? *

Please Describe Any Horse Experience You May Have:

Special Requests:

How Did You Hear About The Serenity Ranch? *

Please Add anything Additional That You Would Like To Share:

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