HerHEALTHYLife Application

HerHealthyLife Application
Women Veterans: Before continuing, please confirm that you will be able to upload a copy of your DD214 or another official document verifying your military service at the end of this application.*

Yes, I can provide the required documentation.Not Applicable
Daughters of Veterans: Please confirm that you can provide both your parent’s military service verification and your birth certificate showing your veteran parent’s name at the end of this application.*

Yes, I can provide the required documentation.Not Applicable
If you are not able to provide the required documentation at this time, please hold off on submitting the application until you are able to do so. If you have the necessary documents, you may proceed.
Name*

First NameLast Name
Phone*
Format: (000) 000-0000.
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you service-connected?*
Discharge Type*
Entry Date*

MonthDayYear
Date
Are You a Combat Vet?*

YesNo
Discharge Date*

MonthDayYear
Date
Branch of Service?*
What Component*
ex: National Guard, Reserve, Active Duty, etc.
Please Acknowledge*

(You will be required to produce proof of military Service such as a DD214 or other official documentation)
Height*
Age*
Weight*
To your knowledge, do you have any heart, respiratory, or any other medical issues that could affect your ability to exercise?*

YesNo
This is a 4-month program. Will you commit to at least 2-3 times a week to complete tasks required by the program?*

YesNo
Do you have a Fitbit or something similar to track your steps and heartrate?*

YesNo
Most of your work will be online. Occasionally, you will be required to meet up in person with facilitator. Are you will to do that?*

YesNo
List 3 things you expect to happen as a result of you participating in this program:*
How did you hear about HerHEALTHYLife?*

VAWebsiteSocial MediaGoogle or other search engine211Previous attendeeAnother veteranHerVOICE Monthly NewsletterWomen Veterans Ignited Staff MemberOutdoor BillboardIndoor digital billboard inside a restaurantOther
Thank you for providing the requested information. Please upload your military verification in the section below, and don’t forget to submit the application to complete the process.
File Upload*

Accepted files: PDF, JPG, JPEG, PNG. Please note, the max size per document is 5 Mb / 40,000 Kb.
Cancelof
Please verify that you are human by typing in the characters shown.*
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HerHealthyLife Application