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Retreat Application

Who will be participating?

Adult Adult and Children Children

You are signing for yourself You are signing for yourself and one or more children You are signing for one or more children

First Name *

Last Name *

Your Date of Birth *

Phone *

Email Address *

Address *

Address Line 2

City *

State *

Zip *

Retreat Date*

Country*

Gender*

What category best describes your race?
American Indian/Alaska Native
Asian
Black of African American
Native Hawaiian/Other Pacific Islander
White
Some other race
Declined
Unavailable/Unknown

Optional - non-identifiable demographic statistics are often requested on grant applications for retreat funding.

Branch of Service*

Rank*

Military/Work Status*

Service Begin Date*

Service End Date

Please list, if any, the locations and dates of deployments/tours*

State ID (License)/Military ID*

In an effort to prevent stolen valor, we need to verify your military service. Please provide us with a copy of your DD214 or Military ID.

Additional Attendees

Warrior Ranch Foundation welcomes assistants you may need.

Do you receive Caregiver support?*

Yes

If you answer yes, please provide the name of the Caregiver below

Caregiver Full Name

If answering yes to previous question

Caregiver Attending?

Yes

Caregiver Phone Number*

Caregiver Email*

EMERGENCY CONTACT INFO*

Name: Phone #:

Medical Information

Information gathered is to better tailor our program to fit your needs. If “yes” to any of the below, please describe in text box.

Current Medical Condition(s)

Current Symptoms*
Headaches
Difficulty with Sleep
Pain
Dizziness
Vision Difficulties
Light Sensitivity
Hearing Difficulties
Amputee
Balance Problems
Memory Problems
Concentration Problems
Depression
Anxiety
PTSD
TBI Brain Injury
Suicidal Thoughts / Behavior
Homicidal Thoughts/Behavior
Dissociative episodes
Seizures
Burn
Problem making decisions
Difficulty Communicating Clearly
Other

Please check all that apply

Please include any details about the injuries you checked that you think would be helpful for our program manager to know.

Do you have a history of substance abuse?*

Yes

If so, please explain

Other Medical Conditions

Please list any dietary constraints

If caregiver is also atending, include their dietary constraints, if any, as well.

Have you ever been charged or convicted of a violent felony?*

Yes

How did you hear about Warrior Ranch Foundation?

It is unnecessary to have any horse experience to participate in our program. For informational purposes only and to tailor our program to suit your needs, if you have equine experience please let us know the extent.

Background Check*

We recognize that people make mistakes in life, some of which may result in a criminal charge. There are some criminal charges that would disqualify you from participating in Warrior Ranch Foundation programs (such as animal abuse, sexual assault). By checking this box, you are authorizing Warrior Ranch Foundation to run a confidetial criminal history search.

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I certify that my answers are true and complete to the best of my knowledge. I authorize a background check through National Center for Safety Initiatives