ROEVER FOUNDATION APPLICATION
*Please fill out the form completely
**Add NA to any questions that are not applicable
***One application per participant
PERSONAL INFORMATION
Legal Last Name *
Legal First Name *
Preferred Name
If you have a preferred name or nickname that we should call you
Mailing Address *
City *
State *
Zip Code *
Phone Number *
Primary Contact Number
Email Address *
Gender *
Required
Please state: *
Required
Date of Birth *
00/00/0000
Height *
Weight *
Marital Status *
Required
Name of Spouse
Spouse Email Address
Spouse Phone Number
Do you have children? *
Required
Last 4 digits of your Social Security Number *
Please DO NOT state your entire number for security reasons.
Are you affiliated with any religion? *
(Christian, Catholic, ect.)
EMERGENCY CONTACT INFORMATION
Emergency Contact Name *
Relationship with Emergency Contact? *
Required
Emergency Contact Phone Number *
(000) 000-0000
Primary Physician's Name *
Primary Physician's Phone *
(000) 000-0000
PROGRAM INFORMATION
What type of programs are you interested in attending? *
Required
Which location are you interested in attending? *
Required
Will you be attending the program as a: *
Required
If you are coming with a specific group, please list the group name.
What do you hope to receive from our program? *
What size t-shirt do you wear? *
Adult Unisex Sizes only.
Required
We offer horseback riding at Eagles Summit. Do you have any experience riding horses? *
Required
MILITARY HISTORY
Military Status *
Required
Military Branch *
Required
Which military installation are you currently stationed?
Military Job Description
Military Rank
If retired, what is your separation date?
00/0000
MEDICAL HISTORY
Were you injured while serving in the military? *
Required
Has the Veterans Administration granted you a percentage of disability? *
Required
If so, please state your percentage of disability.
Where were you injured?
Physical location (US, Iraq, ect.)
What type of injury(s) did you sustain?
Do you have current medical issues?
(PTSD, Depression, Anxiety, ect...)
Does your physician require a medical release for you to attend our program? *
If so, a separate form is required to be completed by your doctor.
Required
Do you require assistance while you are staying with us? *
(Assistance with dressing, bathing, eating, ect...)
Required
In order to be ambulatory, do you require any of the following? *
Required
Are you on a special diet required by your doctor? *
Required
If a special diet is required, please explain.
Do you have any food allergies? *
Required
If so, please list what you foods you are allergic to.
Are you able to participate in recreational activities? *
Required
EDUCATIONAL HISTORY
High School *
Required
College *
Required
If you graduated college, please tell us your major and degree.
REFERRAL INFORMATION
Who referred you to our program? *
Required
What is their name? *
What is their phone number or email address? *
ELECTRONIC SIGNATURE
By typing your name below, you are stating that all the information you provided is true.
Signature *
Please type your legal name. (For minors, please state the parents name.)
Submit
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