GratitudeAmerica Military Support Retreat Application
***Please only fill out one application. We will attempt to accommodate your first retreat choice - you will be selected for the most appropriate retreat by our staff. Filling out more than one application only makes it more difficult to process your application.***

GratitudeAmerica Military Support Retreats are an integrative intensive retreat program for post‐9/11 era combat veterans and their primary support persons (this may include a friend, family member, parent, spouse, girlfriend/boyfriend, caregiver, etc.).

GratitudeAmerica is providing this application online for your convenience. If you need assistance in filling out the application, please call or email Michael Anthony, or ask your referring provider to assist you.

Michael Anthony, Executive Director, GratitudeAmerica 912-674-0332
michael@gratitudeamerica.org

We are grateful to you for taking the time to fill out the retreat application. We recognize that some of the information may be personal and you may not want to share it. We have designed the application to help us learn a little more about you to ensure a great experience for you during the retreat. There will be plenty of opportunity for feedback during the retreat as well. Our mission is to provide service members and their primary support persons with an opportunity to relax, restore connections with others who have experienced deployments, and to enjoy recreation in a relaxed and beautiful setting.

DIRECTIONS:
1. Complete the ENTIRE questionnaire as honestly as possible. It will take approximately 20 minutes to complete the application.

2. Space at the retreat is limited. You will be contacted to learn whether you will be participating in our retreat.

3. Retreat applicants who are not able to be accommodated will automatically be considered for future retreats.

4. Please keep in mind that we require participants to arrive on time and stay for the entire retreat to realize the full benefit
of the experience.

5. Thanks for your efforts and for your support. We appreciate YOU!

PERSONAL INFORMATION
All information provided is confidential and will be used only by GratitudeAmerica Military Support Retreat staff for retreat planning and will not be provided to any other organization.

Which retreat date/location are you applying for? *
Veteran First Name: *
Your answer
Veteran Last Name: *
Your answer
Veteran Gender: *
Veteran E-mail Address *
Your answer
Veteran Cell Phone *
Your answer
Home Address
Your answer
City *
Your answer
State *
Your answer
Zip Code
Your answer
Veteran Date of Birth *
MM
/
DD
/
YYYY
What is your current relationship status? *
Name of Primary Support Person who you bringing to the retreat: *
Your answer
Gender of Primary Support Person *
What is your current role/relationship with your Service Member/Veteran? *
How many years have you known your Primary Support Person? *
Your answer
Support Person Phone
Your answer
Support Person E-mail Address
Your answer
Approximate Start of Veterans Military Service *
MM
/
DD
/
YYYY
Approximate End of Veterans Military Service (if still serving list today's date) *
MM
/
DD
/
YYYY
Branch of Service (Note: You may select more than one answer below. For example, if you were Army National Guard, you would select "Army" and "National Guard"; if you have served in both Army and Air Force (active components) you would select both "Army" and "Air Force"). *
Required
Number of Combat Zone Deployments *
Your answer
Briefly describe your Combat Zone Deployments or Stateside Missions: Please include dates of deployment, location, MOS/AOC (For example, Iraq, 2005-6, Operations Officer; or OEF, 2003-4, 11B) *
Your answer
Please indicate your current military service status: *
Highest military rank (current or at discharge/retirement):
Please select any of the following health concerns that you, the service member currently experience: *
Required
Please provide any additional information about the health concerns you described above:
Your answer
Please describe any physical limitations you have and any assistance/accommodations you will need during the retreat (e.g., in a wheelchair, have a prosthesis, hearing impaired, etc):
Your answer
Please select any special dietary requirements you have:
Do you have a service canine?
Are you or your service member/primary support person currently participating in any of the following treatment or support groups (select all that apply): *
Required
Have you attended any previous retreats for service members/families? (describe) *
Your answer
What do you hope to gain from participating in this retreat? *
Your answer
How did you learn about our Military Support Retreats? Did someone refer you, if so, who?
Your answer
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