2017 Stand Down Veteran Registration Form
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Last Name
Your answer
First Name
Your answer
Middle Initial
Your answer
Date of Birth
MM
/
DD
/
YYYY
SSN (Last 4 digits)
Your answer
GENDER
PLEASE SELECT FROM GENDER options 1 - 3
Gender - option 1
Gender - option 2
Gender - option 3
ETHNIC GROUP
PLEASE SELECT ALL THAT APPLY FROM GROUP(S) 1 - 6
Ethnic Group - 1
Ethnic Group - 2
Ethnic Group - 3
Ethnic Group - 4
Ethnic Group - 5
white
Ethnic Group - 6
ADDRESS, PHONE AND EMAIL
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone
Area code and Number
Your answer
email address
Your answer
MARITAL STATUS AND FAMILY INFORMATION
Please select from Marital Status options 1 - 3
Please select all that apply from Number and age of children options 1 - 12
Current Marital Status - option1
Current Marital Status - option 2
Current Marital Status - option 3
Is your spouse with you at Stand Down?
Do you have minor children?
Do you have minor children living with you?
Do you have children attending Stand Down with you?
Number of children and age - option 1
Number of children and age - option 2
Number of children and age -option 3
Number of children and age - option 4
Number of children and age -option 5
Number of children and age - option 6
Number of children and age -option 7
Number of children and age - option 8
Number of children and age - option 9
Number of children and age - option 10
Number of children and age - option 11
Number of children and age - option12
MILITARY BRANCH OF SERVICE
Please select all Branch of Service that apply from options 1 - 13
Military Branch of Service - option 1
Military Branch of Service - option 2
Military Branch of Service - option 3
Military Branch of Service - option 4
Military Branch of Service - option 5
Military Branch of Service - option 6
Military Branch of Service - option 7
Military Branch of Service - option 8
Military Branch of Service - option 9
Military Branch of Service - option 10
Military Branch of Service - option 11
Military Branch of Service - option 12
Military Branch of Service - option 13
DATES OF MILITARY SERVICE
Date entered active duty
MM
/
DD
/
YYYY
Date separated from active duty
MM
/
DD
/
YYYY
WHERE YOU SERVED
Please select all that apply from Which War Zone options 1 - 7
Have you ever served in a War Zone?
Required
Which War Zone - option 1
Which War Zone - option 2
Which War Zone - option 3
Which War Zone - option 4
Which War Zone - option 5
Which War Zone - option 6
Which War Zone - option 7
Other
Your answer
TYPE OF DISCHARGE RECEIVED
Please select from Option 1 - 9
Type of discharge received - option 1
Type of discharge received - option 2
Type of discharge received -  option 3
Type of discharge received - option 4
Type of discharge received - option 5
Type of discharge received - option 6
Type of discharge received - option 7
Type of discharge received - option 8
Type of discharge received - option 9
VA benefits
Have you ever filed for VA benefits?
Required
Do you need assistance with filing a VA claim?
Required
HOUSING STATUS
Please select from options 1 - 8
What is your current housing status? option 1
What is your current housing status? option 2
What is your current housing status? option 3
What is your current housing status? option 4
What is your current housing status? option 5
What is your current housing status? option 6
What is your current housing status? option 7
What is your current housing status? option 8
IF HOMELESS, WHAT CAUSED YOUR HOMELESSNESS?
Select all that apply from Cause of Homelessness options 1 - 9
Cause of Homelessness? option 1
Cause of Homelessness? option 2
Cause of Homelessness? option 3
Cause of Homelessness? option 4
Cause of Homelessness? option 5
Cause of Homelessness? option 6
Cause of Homelessness? option 7
Cause of Homelessness? option 8
Cause of Homelessness? option 9
HOW LONG HAVE YOU BEEN HOMELESS?
Please select from How Long Have You Been Homeless - options 1 - 6
How Long Have You Been Homeless? option 1
How Long Have You Been Homeless? option 2
How Long Have You Been Homeless? option 3
How Long Have You Been Homeless? option 4
How Long Have You Been Homeless? option 5
How Long Have You Been Homeless? option 6
VA / PUBLIC ASSISTANCE
Please select all that apply Forms of Assistance Received options 1 - 10
Forms of Assistance Received - option 1
Forms of Assistance Received - option 2
Forms of Assistance Received - option 3
Forms of Assistance Received - option 4
Forms of Assistance Received - option 5
Forms of Assistance Received - option 6
Forms of Assistance Received - option 7
Forms of Assistance Received - option 8
Forms of Assistance Received - option 9
Forms of Assistance Received - option 10
VA BENEFITS RECEIVED OR CLAIMED
Please select all that apply from Types of VA benefits received or claimed options 1 - 9
Types of VA benefits received or claimed - option 1
Types of VA benefits received or claimed - option 2
Types of VA benefits received or claimed - option 3
Types of VA benefits received or claimed - option 4
Types of VA benefits received or claimed - option 5
Types of VA benefits received or claimed - option 6
Types of VA benefits received or claimed - option 7
Types of VA benefits received or claimed - option 8
Types of VA benefits received or claimed - option 9
Have you received medical treatment at the VA Clinic in Yuba City?
ENROLLED IN VA HEALTH CARE
Are you enrolled in VA Healthcare ? option 1
Are you enrolled in VA Healthcare ? option 2
If you are not enrolled in VA Healthcare, why not
Your answer
Are you registered at the VA Clinic in Yuba City?
STAND DOWN ATTENDANCE
Have you ever attended a Stand Down before? option 1
Have you ever attended a Stand Down before? option 2
If you have attended a Stand Down before, what year(s)?
Your answer
If you have attended a Stand Down before, where?
Your answer
PLAN TO ATTEND
Please select all that apply from options 1 - 3
What day(s) do you plan to attend Stand Down? option 1
What day(s) do you plan to attend Stand Down? option 2
What day(s) do you plan to attend Stand Down? option 3
DO YOU PLAN TO STAY OVERNIGHT?
Please select all that apply from options 1 - 2
Do you plan to stay overnight? option 1
Do you plan to stay overnight? option 2
WHAT SERVICES WILL YOU BE SEEKING AT STAND DOWN?
Please select all that apply from options 1 - 13
Are you rated 100% disabled by VA
Required
Are you eligible to receive Dental services from VA?
Required
Do you have private Dental Insurance?
Required
Are you eligible to receive Vision services from VA?
Required
Do you have private Vision insurance?
Required
What services will you be seeking at Stand Down? option 1
What services will you be seeking at Stand Down? option 2
What services will you be seeking at Stand Down? option 3
What services will you be seeking at Stand Down? option 4
What services will you be seeking at Stand Down? option 5
What services will you be seeking at Stand Down? option 6
What services will you be seeking at Stand Down? option 7
What services will you be seeking at Stand Down? option 8
What services will you be seeking at Stand Down? option 9
What services will you be seeking at Stand Down? option 10
What services will you be seeking at Stand Down? option 11
What services will you be seeking at Stand Down? option 12
What services will you be seeking at Stand Down? option 13
What other services will you be seeking at Stand Down?
Your answer
It is required that you provide proof of your Veteran Status (VA Medical Card, VA ID CARD, DD-2214) and a Photo ID to the gate at the time of check-in. August 24-26, 2017. Gates open at 9:00 AM daily. Thank you!
Your answer
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