Application | shields-and-stripes.tempurl.host

Contact Information
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState/Province

Zip Code
Employment Status
Are/were you a first-responder?*

PoliceFireEMT/ParamedicDispatcherOther first-responder jobNo first-responder experience
Military only: Specify military status*

Active DutyGuardReservistVeteran/RetiredNo military experience
Military only: Specific Branch

ArmyNavyMarine CorpsAir ForceSpace ForceCoast GuardNational Guard
Military only: AFSC/MOS/Rating or Rate
Military Only: Job Title
Military Only: Have you ever served in Special Forces?

YesNo
Years served as a first-responder and/or Veteran*
Background Information
Tell us your story or what happened that led you to Shields & Stripes.*
Do you want to improve your physical, mental, and cognitive performance? Why or why not?*
Explain your support system, or lack of one.*
Why have you chosen Shields & Stripes for assistance?*
Feel free to provide us with any other information you feel we should know.
By typing your name below, you confirm that you have read our FAQ prior to submitting your application.*
Please verify that you are human*
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Contact Information