Applicant Information Today's Date Full Name Address Phone Email Date Available Date of Birth Are you a Combat Veteran?YesNo If no, did you receive Imminent Danger Pay?YesNo Do you have a VA disability rating?YesNo If yes, what%? Have you been diagnosed with PTSD?YesNo If yes, what%? If yes, what are your symptoms? Marital Status Spouse Spouse Child Child Child Child Emergency Contact Information Name Address Relationship Military Service Branch Service Date From To Rank at Discharge Type of Discharge? If medically retired, at what %? Injuries Prescribed Medications Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. I have attached a copy of my DD214 and VA Disability Letter (if applicable) and it is true and correct to the best of my knowledge. If this application leads to admission into Camp Hope, I understand that false or misleading information in my application or interview may result in my release. Date Questions? Call 877-717-PTSD (7873) After you submit application, please scan a copy of your DD214 and VA Disability Letter and email to email@example.com What to Bring With You 1 Week of Clothes Shoes Medications You won’t need to bring anything else to complete the program.