HerTOTALWellness Application

HerTOTALWellness 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 will be able to upload 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*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In which Florida county do you reside?

Baker CountyClay CountyDuval CountyNassau CountySt. Johns CountyPutnam CountyOther
Branch of Service*
What Component*
ex: National Guard, Reserve, Active Duty, etc.
Are You A Combat Vet?*

YesNo
Discharge Type*

HonorableGeneral Under Honorable ConditionsOther Than HonorableBad ConductDishonorableOther
Are you service-connected?*

YesNoOther
Entry Date*

MonthDayYear
Date
Discharge Date*

MonthDayYear
Date
Acknowledgment Required:*

I understand that I will be required to provide proof of military service, such as a DD214 or other official documentation.
Are you able to commit to 4-week workshops on Tuesdays & Thursdays?*

YesNo
Employment Status*

EmployedUnemployedSearchingSelf-EmployedStudentUnderemployed (make less than $20/hourNot SearchingRetiredOther
Level of Education*

High school graduate or equivalentSome college (less than 2 years)Associate degreeUndergraduatePost-graduateSeeking higher educationSeeking certification programOther
How did you hear about HerTOTALWellness?*

VAWebsiteSocial MediaGoogle or other search engine211Previous attendeeAnother veteranHerVOICE Monthly NewsletterEventWomen Veterans Ignited Staff MemberOther
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.
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Please verify that you are human by typing in the characters shown.*
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