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Kristopher Workman
(Z) Skills4Life - Veteran Application
Step 1 of 8
12%
Applicant Name
*
Email Address
*
Home Phone
*
Cell Phone
Current Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Family Information
Please fill out the information below if you have a spouse or children that you would like to be considered for an event with you.
Family Member 1
Family Member 1 Relationship
DOB: Family Member 1
MM
DD
YYYY
Family Member 1 Age
Please enter a number from
0
to
100
.
Family Member 2
Family Member 2 Relationship
DOB: Family Member 2
MM
DD
YYYY
Family Member 2 Age
Please enter a number from
0
to
100
.
Family Member 3
Family Member 3 Relationship
DOB: Family Member 3
MM
DD
YYYY
Family Member 3 Age
Please enter a number from
0
to
100
.
Family Member 4
Family Member 4 Relationship
DOB: Family Member 4
MM
DD
YYYY
Family Member 4 Age
Please enter a number from
0
to
100
.
Family Member 5
Family Member 5 Relationship
DOB: Family Member 5
MM
DD
YYYY
Family Member 5 Age
Please enter a number from
0
to
100
.
Family Member 6
Family Member 6 Relationship
DOB: Family Member 6
MM
DD
YYYY
Family Member 6 Age
Please enter a number from
0
to
100
.
Military Information
What was your MOS/AFSC/NEC
*
Rank/Paygrade
*
Branch of Service
*
US Army
Air Force
Marine Corps
Navy
US Coast Guard
Duty Status
*
Active
Reserve
Guard
Retired
Medically Retired
Disabled Veteran
Military Awards
Do you have a Purple Heart?
*
Yes
No
Pending
Please select only one.
Military Awards
*
Purple Heart
Medal of Honor
Silver Star
Army Distinguished Service Cross
Navy Cross
Air Force Cross
Coast Guard Cross
Distinguished Flying Cross
Bronze Star Medal w/ Valor
Bronze Star Medal
Commendation Medal w/ Valor
Commendation Medal
Achievement Medal w/ Valor
Achievement Medal
Combat Infantryman Badge
Combat Action Badge
Combat Medic Badge
Combat Action Ribbon
Combat Action Medal
Afghanistan Campaign Medal
Inherent Resolve Campaign Medal
Iraq Campaign Medal
Vietnam Service Medal
Global War on Terrorism Service Medal
Global War on Terrorism Expeditionary Medal
NONE LISTED
Interest & Experience
Programs you are interested in
*
Hunting
Fishing
Golfing
Archery
Bow Hunting
Family Outings
Please select all that interest you.
Experience
Have you completed your states Hunter Safety Course?
*
Yes
No
Do you have any hunting experience? If yes, please explain in the field below.
*
Yes
No
Please describe your hunting experience here:
*
Do you have any fishing experience? If yes, please explain in the field below.
*
Yes
No
Please describe your fishing experience here:
*
Do you have any golfing experience? If yes, please explain in the field below.
*
Yes
No
Please describe your golfing experience here:
*
Do you have any Bow Hunting experience? If yes, please explain in the field below.
*
Yes
No
Please describe your Bow Hunting experience here:
*
Do you have any Archery experience? If yes, please explain in the field below.
*
Yes
No
Please describe your Archery experience here:
*
What type of family events are you interested in? Please explain if applicable.
*
Other Interests:
Why are you applying for the Skills4Life Program?
*
How will the Skills4Life program aid you in your recovery?
*
What other organizations have you participated in events with? Please list and explain below.
*
Medical Information
Disability Percentage
0
10
20
30
40
50
60
70
80
90
100
Are you currently taking any medications that would prevent you from participating in any events? If yes, please explain below.
Yes
No
If yes, please explain here.
*
Do you have a service dog? If yes, please list breed, sex, weight, and if they are current on vaccinations.
Is the animal a certified licensed service animal?
Yes
No
Do you, or your family, have any special needs? If yes, please explain.
References
Military Reference Name
Military Reference Phone Number
Personal Reference Name
Personal Reference Phone Number
Comments:
Demographics
We ask that you complete the following questions which will help MWSF in pursuit of additional funding for its programs through grants and sponsorships. Your answers will not impact your application process. The data collected is protected in accordance with the Privacy Act (93-579). Unauthorized disclosure of this information constitutes a violation of the Privacy Act. You are not required to provide this information, but are encouraged to answer honestly, so that future applicants may continue to benefit from our programs.
Applicant's Gender?
*
Female
Male
Other
Decline to Answer
Which race/ethnicity best describes you?
*
Non-Hispanic White or Euro American
Black, Afro-Caribbean or African American
Latino or Hispanic American
East Asian or Asian American
South Asian or Indian American
Middle Eastern or Arab American
Native American or Alaskan Native
Multiple Ethnicity/Other
Decline to answer
What is the highest degree or level of school you have completed? If currently enrolled, highest degree received?
*
Some high school, no diploma
High school graduate, diploma or GED
Some college credit, no degree
Trade/technical/vocational training
College graduate
Some post-grad work
Post-grad degree
Decline to answer
Age when entered the military
*
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40+
Decline to answer
Number of military years served?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20+
Decline to Answer
Have you been diagnosed with PTSD?
*
Yes
No
Decline to Answer
Have been diagnosed with a Traumatic Brain Injury (TBI)?
*
Yes
No
Decline to Answer
In the last 12 months have you spent the night in a shelter, mission, church, abandon building, car, park, or street?
*
Yes
No
Decline to Answer
Statement of Truth
*
Providing false information can cause a review and change in applicant status and may affect your eligibility to participate in any MWSF program. By submitting the application, you confirm that you all the information contained in it, is truthful to the best of your knowledge. And that you give Military Warriors Support Foundation permission to contact you regarding our programs.
Agree
Disagree
