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
Your answer
Legal First Name
Your answer
Preferred Name
If you have a preferred name or nickname that we should call you
Your answer
Mailing Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone Number
Primary Contact Number
Your answer
Email Address
Your answer
Gender
Required
Please state:
Required
Date of Birth
00/00/0000
Your answer
Height
Your answer
Weight
Your answer
Marital Status
Required
Name of Spouse
Your answer
Spouse Email Address
Your answer
Spouse Phone Number
Your answer
Do you have children?
Required
Last 4 digits of your Social Security Number
Please DO NOT state your entire number for security reasons.
Your answer
Are you affiliated with any religion?
(Christian, Catholic, ect.)
Your answer
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
Your answer
Relationship with Emergency Contact?
Required
Emergency Contact Phone Number
(000) 000-0000
Your answer
Primary Physician's Name
Your answer
Primary Physician's Phone
(000) 000-0000
Your answer
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.
Your answer
What do you hope to receive from our program?
Your answer
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?
Your answer
Military Job Description
Your answer
Military Rank
Your answer
If retired, what is your separation date?
00/0000
Your answer
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.
Your answer
Where were you injured?
Physical location (US, Iraq, ect.)
Your answer
What type of injury(s) did you sustain?
Your answer
Do you have current medical issues?
(PTSD, Depression, Anxiety, ect...)
Your answer
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.
Your answer
Do you have any food allergies?
Required
If so, please list what you foods you are allergic to.
Your answer
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.
Your answer
REFERRAL INFORMATION
Who referred you to our program?
Required
What is their name?
Your answer
What is their phone number or email address?
Your answer
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.)
Your answer
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