2022 Veteran Stand Down Registration 
Please complete this form in preparation for the 2022 Veteran Stand Down scheduled for Saturday, September 24 at Nova Southeastern University. This information will improve the level of services that we can provide to you during the Veteran Stand Down. Information will only be shared with other nonprofit, government, or private agencies who are providing services through Stand Down. 

All information will be removed from the secure Google Drive after the Stand Down. 
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Basic Demographic Information
First and Last Name *
Last four of SSN *
Date of Birth *
MM
/
DD
/
YYYY
Telephone Number *
Email Address *
Address *
My address: *
Military Service
Branch of Military Service *
Year of Discharge *
Type of Discharge *
Did you serve in a combat zone? *
Current Situation
Are you registered for VA healthcare? *
I am receiving the following VA benefits/services *
Required
How do you plan on getting to the Stand Down? *
Do you have transportation or mobility issues? *
Are you housed but at risk of being homeless? *
If you answered yes to risk of homelessness, explain why. 
Are you experiencing homelessness (including living in a shelter). *
If you are homeless, please answer the following questions:
Where are you sleeping?
What are your most immediate needs?
How long have you been experiencing homelessness?
Do you have a point of contact that can help us connect with you? (e.g. case manager, social worker, etc.)
Clear selection
If yes, please provide name and phone number for your point of contact. 
Immediate Needs
Please mark any immediate needs *
Required
Health Care Needs *
Required
Mental Health Needs *
Required
Legal Needs *
Required
Do you need assistance obtaining any of the following documents? *
Required
Please select any of the situations that may apply to you.  *
Required
NSU Veterans Access Clinic 
(Only Complete if you need Dental or Vision services)
Nova Southeastern University's Veterans Access Clinic can provide limited medical services at Stand Down, including optometry and dental screenings, to certain Veterans** at no cost to you by utilizing funds from the State of Florida. 

Dental - dental screenings and follow up appointments.
Optometry - eye exams, glasses, etc. 

If you answer "yes" to the following questions you may be eligible for these services at Stand Down. If you are eligible for free healthcare services from NSU, additional paperwork will be required. Forms will be sent to you prior to the event. 

Eligibility will be confirmed on site prior to services being provided. You must provide proof of discharge status via form DD-214 and government identification card. 

**NSU Veterans Access Clinic can only provide these services to Veterans with an honorable or general, under honorable conditions discharge who do not have insurance covering these services. 
I am a Veteran
Clear selection
My discharge status is honorable or under honorable conditions.
Clear selection
I do not have private health insurance for dental or optometry (not including VA healthcare).
Clear selection
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