Application for Assistance
When applying for assistance, you are required to submit your redacted dd214 and VA Rating breakdown. You can fax all documentation to 865-322-9874 Or email to theresa.botts@spartanweekend.org In order to qualify for a mobility device you must be 50% independently rated for mobility, or 30% and higher for a service connected incurable auto immune disease, such as MS or ALS
Application Information
Date *
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Date of Birth *
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First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone # *
Your answer
What type of phone is this? *
Email Address *
Your answer
Veteran Employment Status. *
What are you applying for? *
NOTE: Mobility Devices require a DoD or VA rating of a minimum of a 50% rating for mobility related issues and an Honorable Discharge or proof of active duty status. All other requests require a minimum 30% rating. If you are applying for Spartan Weekend attendence or a Caregivers Retreat. Refer to www.spartanweekend.org under EVENTS for that application.
Military Service Information
Service Status? *
Date of Discharge *
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Branch of Service? *
Military Rank?
Your answer
Type of Discharge ? *
Purple Heart recipient?
Number of Deployments?
Your answer
Date of last deployment?
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DD
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YYYY
When & Where were you deployed?
Your answer
Disability Information
VA Disability Rating?
Your answer
Breakdown of VA disability rating per injury. *
Your answer
Nature of wound, illness, or injury *
VA Benefits Utilized *
Required
Have you received assistance from another organization? *
If yes, what organization?
Your answer
Additional Comments
Your answer
*DISCLAIMER* Your Information will not be shared with a 3rd party without your acknowledgment and approval.
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