Cross the Divide Application
Please fill in the form below.
Full Name
*
Rank/Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
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Alabama
Alaska
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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Washington
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Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Date of Birth
Status:
*
Active Duty
Retired
Medical Retired
Veteran/Military Spouse/Child
Other
Service Related Injury (if any), including PTSD, TBI & MST:
*
Yes
No
Describe Injuries (if any)
Purple Heart Recipient:
Yes
No
VA Rating, (Retired/ Separated only)
Please include a copy of VA Rating (Ret./Sep. only).
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Please include a copy of current orders (AD) or Certified DD 214 (Retired/Separated)
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Family:
Married
Single
Spouse Name
Children?
Yes
No
Children(s) Names/Ages
Next of Kin (NOK) / Emergency Contact Information:
Enter NOK/Emergency contact Name, Phone and Email below
NOK Name
Name/ Relationship
NOK Phone
-
Area Code
Phone Number
NOK Email
example@example.com
Additional information:
Tell what activities you are interested in.
Backpacking
Fishing
Hunting
Women's Retreat
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