Healing America’s Heroes Four Day Program Application

Healing America’s Heroes Four Day Program Application

Complete the application based on the referenced PDF. Preserve the original sectioning and wording as closely as possible.
Program Info & Eligibility
I have read and understand the information above
Preferred workshop date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Alternate workshop date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Information
Legal name

First NameMiddle NameLast Name
Preferred name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City, state, ZIP
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred contact method

Other
Best time to contact you
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Primary phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Alternate phone
Please enter a valid phone number.Format: (000) 000-0000.
May HAH contact this person in an emergency?
Service and Eligibility
Service category

Other
Branch, agency, or service type
Current status

Other
Years of service
Discharge/separation date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rank or position
Military specialty or job role
Duty locations/deployments
State of residence
Proof of service attached
Program Interest and Goals
How did you hear about Healing America’s Heroes?
Why are you interested in attending this four-day program?
What would you most like to learn, experience, or take away from the program?
What strengths, interests, or supportive practices do you currently rely on?
Participation Readiness & Group/Activity Considerations

Readiness Statements

Rows	Yes	Need to discuss
I am prepared to participate in a structured group setting.
I can follow a daily schedule and group guidelines.
I am comfortable engaging in shared activities with other participants.
I can manage my energy and take breaks when needed.
I am open to discussing any concerns that may affect participation.

Group and Activity Considerations

Other
Health, Accessibility, and Medications
Can you participate safely in light-to-moderate daily activities?
Mobility or accessibility needs

Other
Communication or sensory accommodations
Do you have any serious heart, lung, neurological, or other condition that could affect participation?
Allergies or significant sensitivities
Dietary needs

Other
Do you use CPAP, oxygen, a nebulizer, or other medical equipment?
If yes, please describe the equipment and any setup needs
Do you need medication refrigeration?
Do you need sharps disposal?
Do you carry any emergency medication with you?
Please explain any condition, allergy, equipment, activity restriction, or accommodation needs
I understand I am responsible for managing my medications during the program
Current Safety, Support, and Substance Use
Are you currently experiencing thoughts of harming yourself or others?
If yes or unsure, please explain
Which of the following best describes your current substance use and recovery situation?

Other
Please provide any details about safety, support needs, substance use, or conduct concerns
Activities, Travel, Lodging, and Other Needs
Activities of interest

Other
Equine participation
Height (ft)
Height (in)
Weight (lbs)
Transportation needs or barriers
Lodging needs or concerns
Food allergy requiring strict avoidance
Service animal required
Is there anything else HAH should know?
Interview Scheduling
Preferred days/times for interview
Preferred interview method

Accommodation needed
Certification and Signature
Certification Statement
Applicant Printed Name

First NameLast Name
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization to Communicate with Authorized Person
Authorized Person Name

First NameMiddle NameLast Name
Should be Empty:

Healing America’s Heroes Four Day Program Application

Program Info & Eligibility

Applicant Information

Service and Eligibility

Program Interest and Goals

Participation Readiness & Group/Activity Considerations

Health, Accessibility, and Medications

Current Safety, Support, and Substance Use

Activities, Travel, Lodging, and Other Needs

Interview Scheduling

Certification and Signature