Name:

Address:

City, State, Zip:

,

Phone:

Area Code: - Phone:

Email Address:

Choose a Program:

Choose One Bahama Bay Resort Victorian Resort Kansas City Royals Baseball Washington Nationals Baseball San Diego Padres Baseball Washington Redskins Football San Diego Chargers Football Take Flight Farms

Dates that you would like to use the condo/resort/Baseball tickets: ex: March 6-10, 2006 (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)

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?

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.

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

File Attachment:

DEERS Documentaion: