Applicant Information

Today's Date

Full Name

Address


Phone

Email

Date Available

Date of Birth

Are you a Combat Veteran?

If no, did you receive Imminent Danger Pay?YesNo

Do you have a VA disability rating?

If yes, what%?

Have you been diagnosed with PTSD?

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 warrior@ptsdusa.org


What to Bring With You

  • 1 Week of Clothes
  • Shoes
  • Medications
  • You won’t need to bring anything else to complete the program.