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Warrior Mission: At Ease
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Personal Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Which airport is closest to you?
*
Phone
*
Email
*
Birthdate
*
MM slash DD slash YYYY
Gender
*
Male
Female
T-shirt Size
XS
S
M
L
XL
XXL
Military Information
Branch of Military Service
*
Please list the branch(es) of military in which you were enlisted.
Military Rank
*
What is your current military status?
*
Type of Discharge
*
Do you have a DD 214?
*
Yes
No
Active Service Began Date
*
MM slash DD slash YYYY
Active Service End Date (if applicable)
MM slash DD slash YYYY
Medical Information
Service Member's Medical Information
*
PTSD (post-traumatic stress disorder)
TBI (traumatic brain injury)
Chronic Pain
Amputee
Vision Loss
Hearing Loss
Please check any and all that apply
Please list any other injuries:
Please list any dietary constraints or food allergies:
Additional Injury Comments/Notes:
Other Medical Conditions:
How did you hear about the Warrior Mission: At EASE Program?
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I certify that my answers are true and complete to the best of my knowledge.
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I consent to my submitted data being collected and stored.
Please note that your information is kept confidential in compliance with HIPAA regulations.
Close Menu
Support
Donate Today
Ways to Give
Volunteer
Partners
Donate a Horse
Donate Crypto Currency through BitPay
About
Mission
Staff
Horses & Farm Residents
Board of Directors
Financials
Services
Benefits of Participation
Therapeutic Riding
Hippotherapy
Warrior Mission: At Ease Military Retreats
EASE (EAGALA EAP/EAL)
Corporate Workshops
Military Programs
Visits, Tours & Other Programs
Events
Family Fun Days 2024
Stirrup Hope 2024 – Post Event
Colors of Courage 2023 – Post Event
Contact
