Application | shields-and-stripes.tempurl.host

Program Application

Thank you for taking your first step with us. Please complete the application below and a Shields & Stripes team member will be in contact with you.
Which Program are you available to attend? (Select on-site date available)*

28 July - 15 August8 - 26 SeptemberAvailable for either
Contact Information
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState/Province

Zip Code
Employment Status
Are/were you a First-Responder?*

PoliceFireEMT/ParamedicDispatcherOther First-Responder jobNo First-Responder experience
Are/were you in the Military?*

Active DutyGuardReservistVeteran/RetiredNo Military experience
Military Only: Specify Branch

ArmyNavyMarine CorpsAir ForceSpace ForceCoast GuardNational Guard
Military Only: AFSC/MOS/Rating or Rate
Military Only: Job Title
Military Only: Have you ever served in Special Forces?

YesNo
Years served as First-Responder and/or Military:*
Background Information
Tell us your story or what happened that led you to Shields & Stripes.*
Do you want to improve your physical, mental, and cognitive performance? Why or why not?*
Explain your support system, or lack of one.*
Why have you chosen Shields & Stripes for assistance?*
How did you hear about us?*
To make sure our program is right for you, we have a FAQ Page with some of the most asked questions.
FAQs*

I have reviewed the S&S Frequently Asked Questions to ensure the program is right for me.
Media Release*

I acknowledge that photos and videos may be taken during the program, including candid and group images. I understand these may be used to share the program’s impact and help more military members and first responders receive support. By checking this box, I consent to the use of my image for these purposes.
Please verify that you are human*
Should be Empty:

Program Application

Contact Information

Employment Status

Background Information