New Customer Registration Form

Veterans Freedom Retreat Application
Veteran's Personal Information:

All personal information is confidential and treated accordingly.
Service Member/Veteran Name*

First NameLast Name
Date of Birth*

MonthDayYear
MM-DD-YYYY
Last 4 Digits of SSN*
Ethnicity
Tribal Affiliation
Primary Language
Secondary Language
Name of Spouse/Partner*

First NameLast Name
Spouse/Partner Date of Birth*

MonthDayYear
MM-DD-YYYY
Spouse/Partner Last 4 Digits of SSN*
Spouse/Partner Ethnicity
Spouse/Partner Tribal Affiliation
Spouse/Partner Primary Language
Spouse/Partner Secondary Language
Relationship to Veteran if not Spouse*
Veteran Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Children
Ages/Gender
Home Phone*
Vet Cell*
Spouse/Partner Cell*
Vet E-mail*
example@example.com
Spouse/Partner E-mail*
example@example.com
Service Information:
Branch of Service*
Service Years*
Discharge Date*

MonthDayYear
Date
Combat Zone(s)
Deployment Dates
Units/MOS/AFSC
Awards/Decorations
Current Status*

Active DutyMilitary RetiredVeteranOther
Is Your Spouse/Partner a Military veteran?*

YesNo
If so, please provide the following:
Spouse/Partner Branch of Service*
Spouse/Partner Service Years*
Spouse/Partner Discharge Date*

MonthDayYear
Date
Spouse/Partner Combat Zone(s)
Spouse/Partner Deployment Dates
Spouse/Partner Units/MOS/AFSC
Spouse/Partner Awards/Decorations
Spouse/Partner Current Status

Active DutyMilitary RetiredVeteranOther
Post Traumatic Stress (PTS) Information:

The Veteran must have been diagnosed with a type of PTS or referral by Chaplain or Counselor.
Veteran's PTS was Diagnosed: Date/Year*
What VA or Other Facility?*
Professional Health Care Provider Diagnosis?*

Bipolar DisorderPTSDAnxiety DisordersTBIEating DisordersSubstance DisordersSchizophreniaPersonality DisordersMST
Current/Past Counseling:*
Has your Spouse/Partner been diagnosed with PTS?

YesNo
If so, please have them complete the Partner / Support Person PTS System Questionnaire.
Veteran PTS Symptom Questionnaire:
Veteran Participant's Name*

First NameLast Name
Date*

MonthDayYear
MM-DD-YYYY
Veteran Participant's ID#:
1st & Last Initials + Last 4
Instructions:

Following is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully, and then check one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. Make sure to base your answer on problems that started or got worse after the event.
The Event You Experienced Was:
When the Event Occurred:
Month/Year
Indicate how much you were bothered by each item in the last month. As a guide: Extremely might mean almost every day; Quite a Bit might mean 20 days out of the past 30 days; Moderately might mean ten to 14 days; and A Little Bit might mean any number of days less than ten days out of the last 30. If you were not bothered by the indicated problem at all during the last 30 days, select Not At All.

	Not At All	A Little Bit	Moderately	Quite A Bit	Extremely
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else (who didn’t directly cause the event or actually harm you) for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Feeling irritable or angry or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being “super alert” or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?

Veteran Medical Information:
Service Connected Disability: %*
Condition/Basis*
Prescription Medications:*
Non-Prescribed / Illegal drug / Alcohol Use. What substance and how much / how often?:*
If you are in recovery, how long?:*
NOTE: Bring at least an 8 day supply of your prescription medications.
Veteran's Physical Conditions that require assistance/unique accommodations:

Motorized WheelchairWheelchairWalkerCaneOther
Medical Conditions:*

DiabeticOxygenNebulizerCPAC or similar equipmentOther
Sensitivities or Allergies:

SmokeOther
Dietary:

VegetarianVeganGluten FreeOther
If you require a special diet, please bring your own special foods to be safe.

There will be coffee, a small fridge, ice machine and a microwave in the foyer at the coffee bar area.
Service Animal:

YesNoBreed
(Please bring a kennel for your pet(s) if you leave them in your cabin while in class)

***Fraudulent Representation***
A person who uses an assistance animal with a harness or leash of the type commonly used by persons with disabilities to represent that his or her animal is a specially trained service animal when not trained as such, is guilty of a misdemeanor. Punishable by a fine of not more than $300 and 30 hours of community service. You must bring a copy of the Certfication with you to present to the Camp.

T. C. A., Human Resources Code § 121.006
Other Information:
What first name would you like on your name-tag?
Veteran
Partner
We conduct Equine Therapy on one day of the retreat followed by a very mellow horse “whisperer” session of trying to get a horse to join-up with different Participants to show the importance of allowing the horse to accept you instead of being forced to do what you want them to do. If you want to participate in the joining process, please mark “Horse Whisper.”
Veteran - Horse Whisper?

YesNo
Partner - Horse Whisper?

YesNo
Retreat Information:

Participants should arrive at the retreat location between the hours of 1:00 PM and 3:00 PM. Travel will be paid by the participant. The Retreat does not cover any travel expenses. Lodging and meals will be provided at no cost to the participants. Due to the discussions and nature of these retreats, children under 18 are not allowed to attend.

Comfortable, casual attire such as jeans, shorts, tennis shoes, hats and sunscreen are recommended. Closed toed shoes are necessary for equine therapy. Some activities will require exercise or loose clothing. Cool evening temperatures are expected and sweaters and light jackets are appropriate. Participants should bring pants or ankle length skirts for Native American ceremonies. We also have an evening dinner with dancing, please bring appropriate clothing. Note that there is no laundry facility.

IF YOU ARE A SINGLE VETERAN WHO HAS NO PARTNER, but would be willing to partner with another vet who has completed the retreat and can mentor you during and after your retreat, please indicate below.
Yes, I would like another Veteran to be my PTS support person during and after the retreat.No, I do not want a Veteran support person during and after the retreat. I will continue to seek a partner before my retreat.
For questions relative to the Retreat Application process or dates, please call (940) 867-1863 or (940) 867-3987.

Once your application has been received and processed, you will be notified and placed in one of our first available scheduled retreats. See webpage (vfr.vet) for additional retreat testimonials and information. If circumstances require a particular retreat start date, please indicate below. Availability may be limited.
1st Choice:
2nd Choice:
Please upload a copy of your DD214 or email to DJones@VFR.vet

Cancelof
* All attendees must commit to the FULL seven and a half days of the Retreat. *
Please read the following and check the box to agree to the terms:*

I agree and understand that neither firearms nor illegal substances are allowed on the premises of the retreat, including in vehicles, nor to be consumed at any time during the retreat.I understand that due to the numerous last minute cancellations and No-Shows of previous VFR Registrants, we are asked for a $50 Registration Fee (make check/Money Order out to Veterans Freedom Retreat), to be refunded upon completion of the VFR Retreat.
I/We have read the above and believe all of the answers given on the Retreat Application are true and correct.
We will be sending out e-mails with updates and queries several times before the VFR Retreat begins. Please respond to the e-mails, failure to respond and confirm your attendance by two weeks prior to the retreat will be reason to fill your position with others on the waiting list.
Signature of Service Member/Veteran*

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Date*

MonthDayYear
Date
Signature of Spouse/Partner*

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Date*

MonthDayYear
Date
How did you hear about the Veterans Freedom Retreat?
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Veterans Freedom Retreat Application