Wounded Warriors Family Support

Take Flight Farms Application

Basic Information

First Name Last Name Address City State Zip Phone Email

Resort Information Room Start Date End Date

Military Information
Service Component Pay Grade Number of Dependent(s) Age of Dependent(s) Names of all Family Members Attending Are the dependent children registered in DEERS?

Yes

Will you require help with transportation?

Yes

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

Yes

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

Yes

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

Have you been awarded the Purple Heart?

Yes

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

Yes

If you are currently in a WTU’s, what state is your home residence?
What brought you to the site today?
Would you and your family like to participate in a taped interview while visiting a resort?

Yes

Take Flight Farms Application

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