ROEVER PROGRAM APPLICATION

This is a multiprogram and multidivisional application that covers all Roever and Associates Programs.  As the application is reviewed, we will work with you to ensure the correct documents are submitted.

  • Please fill out the form completely  
  • Add NA to any questions that are not applicable
  • One application per participant
Sign in to Google to save your progress. Learn more
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
Are you affiliated with any religion? *
(Christian, Muslim, None)
EMERGENCY CONTACT INFORMATION
Emergency Contact Name *
Relationship with Emergency Contact? *
Required
Emergency Contact Phone Number *
(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? *
MILITARY & 1st RESPONDER INFORMATION
Military & 1st Responder Branch *
Required
Status *
Required
Military or 1st Responder Job Description
If retired, what is your separation date?
00/0000
MEDICAL HISTORY
Were you injured while serving? *
Required
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...)
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 (gluten or nut sensitive or allergic, etc.)   Please note we cannot guarantee cross contamination.
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? *
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
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy