Operation Second Chance Retreat Application

*Retreat attendance priority is given to Purple Heart recipients, combat injured, or previously deployed service members. All other applications are put into the queue by the date they were received.

Name (as shown on government ID) *

First Name Last Name

Middle Name

Nickname (what do you like to be called if different from your gov't ID)

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Birth Date *

Date

Phone Number *

Area Code Phone Number

Type a question

Male Female

Email *

Confirmation Email Confirm email address

VA Disability Rating *

Attach a copy of your VA Rating letter at the bottom of the application

Please Select the Retreat type(s) that interest you the most in attending? *

Shirt/Jacket Size

Where would you be traveling from? *

Closest airport to your departure location? *

Military Service Branch *

Date Entered Service *

Date

Date Exited Service *

Date

Service Status *

Rank *

Deployed to a Combat Zone *

If yes, to what location(s), number of times, and dates?

Have you received a Purple Heart for your injuries? *

Briefly describe your injuries and/or illness? (annotate which if any are combat related) *

Have you had any surgeries in the last 12 months?

If yes, please explain? Note if this surgery limits your activity in any way?

Do you have any physical limitations and/or special needs/requests while attending? *

List any and all medications you taking (prescribed and not prescribed)? *

Do you have any food allergies and/or dietary restrictions? *

If yes, please list:

Do you have mobility issues? Do you use a wheelchair? Do you need special assistance when you travel? Please describe in detail any special travel handling you need and we'll do our best to accommodate your needs. If you are traveling commercial air, please state the minimum time you need between connecting flights? (We understand every airport is different, and some connections at airports are easier than others, so use your best guess based on your mobility and experience). *

Do you need an ADA compliant room? *

List any special accommodation equipment you would need to be provided on the retreat, such as a shower chair, crib, etc...? *

Would you like to have a spouse or caregiver attend with you for support? *

If yes, list their name as shown on their government ID

First Name Last Name

What do they like to be called if different from their gov't ID

Email

example@example.com

Date of Birth

Date

Phone Number

Area Code Phone Number

Does your spouse/caregiver have any physical limitations that would prevent them from participating in the same physical activities you will be doing? Also note if you or they are pregnant.

Shirt/Jacket Size

Type a question

Male Female

For family retreats, list names and ages of those attending. Names must be as shown on their gov't ID

Would you like to attend with a service dog? *

Only service animals are permitted, no ESAs.

Emergency contact info: (Must not be on the retreat with you) *

First Name Last Name

Relationship to you? *

Phone Number *

Area Code Phone Number

Email *

example@example.com

Have you ever attended an OSC retreat? *

If yes, please describe which type, where, and when?

Have you attended retreats with any other veteran or civilian organization? *

If yes, please describe which type, where, and when?

How did you hear about Operation Second Chance's retreat program? *

Please describe how you and/or your family would benefit from attending one of the listed OSC retreats? *

Please upload a copy of your DD-214 here: *

Browse Files

Does not apply to active duty

Please upload a copy of your VA rating letter here: *

Browse Files

Please upload your DoD photo ID here: *

Browse Files

If you do not have one, then upload your driver's license

Please upload any other supporting documents

Browse Files

Example: Medication list, doctors clearance/restrictions, etc...

Most OSC retreats are available to the wounded/ill/injured service member and their spouse or caregiver. A limited number of retreats are for the entire family. If you are unsure as to which retreats are full family retreat, please contact an OSC representative at retreats@operationsecondchance.org.

TRIP RELEASE FORM ACKNOWLEDGEMENT

The Undersigned acknowledges that his/her participation in this Retreat involves certain inherent risks of physical injury, illness and/or loss of personal property.

The Undersigned also affirms all statements contained in this application are true and correct and understand that false or inaccurate information in the application will be the basis for denial and/or revocation for all support provided by Operation Second Chance.

The Undersigned by his/her execution of this Trip Release Form hereby releases and holds harmless and forever discharges Operation Second Chance, Inc., its officers, employees, directors, agents, volunteers, and staff from any and all claims, causes of action of whatsoever kind or nature, foreseen or unforeseen, arising from or in any way connected with the Retreat.

The Undersigned further recognizes that if not for his/her execution of this Trip Release Form, Operation Second Chance would not permit his/her participation in the Retreat.

The Undersigned further certifies that he/she is an adult and has read the above Trip Release Form carefully before his or her execution of same and that he/she fully understands its terms. In witness whereof the Undersigned has put his or her hand and seal on the date written below.

Participation in a “Retreat” where the undersigned recognizes that every effort will be made to obtain handicap accessible accommodations however; there are instances where this may not be feasible. Therefore, during the trip non-handicap accessible accommodations may be utilized.

Name *

First Name Last Name

Signature *

Clear

PHOTO RELEASE ACKNOWLEDGEMENT:

I grant to Operation Second Chance, its representatives and employees the right to take photographs of me, any of my attending guests, and my property in connection with all Operation Second Chance Retreats. I authorize Operation Second Chance, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Operation Second Chance may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. Other persons attending will be required to fill out and sign a similar release form. I have read and understand the above:

Name *

First Name Last Name

Signature *

Clear