Contact Information
First Name
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Last Name
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Date of Birth
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Email Address
example@example.com
Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Status
What is your duty status?
Active
On Leave
Retired
Are you a military veteran?
Yes
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Are you a first-responder?
Police
Fire
EMT/Paramedic
Dispatcher
Other
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?
Feel free to provide us with any other information you feel we should know.
Please verify that you are human
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