Admission

NOTICE: The information on this form is necessary to evaluate the applicant’s request for admission into our facility. The acceptance of this form does not bind either party to a right of occupancy. Failure to complete the application in its entirety will result in denial of consideration for admission.

Your Name (First, Middle, Last)*

Present Address*

City*

State*

Phone*

Email*

Gender MaleFemale

Date of Birth

Place of Birth

Branch of Military Service*

Years of Service*

Manner of Discharge*

Date of Discharge*

Marital Status
MarriedSingleWidowedDivorced

PLEASE LIST 2 EMERGENCY CONTACT PERSONS.

Name

Relationship

Address

Phone

Name

Relationship

Address

Phone

Do you have any disabilities or special needs that you require accommodations for?
YesNo

If yes, please explain:

Have you ever been diagnosed with or treated for a mental illness?
YesNo

If yes, please explain:

Are you currently or have you ever been treated for alcohol or drug abuse?
YesNo

If yes, please explain:

Do you receive any Veterans Administration benefits?
YesNo

Do you currently have monthly income?
YesNo

If yes, please specify the source and total amounts:

Why are you seeking admission to the Vets for Vets facility?

What are your goals if admitted into the Vets for Vets facility?

Have you ever been charged with a crime?
YesNo

If yes, please specify what crimes you were charged with and the result of the criminal proceedings.

How did you hear about the Vets for Vets organization?

Do you understand that admission into the Vets for Vets facility is discretionary and will be determined solely by personnel of the Vets for Vets organization?
YesNo

I hereby affirm that I have answered this Application for Admission truthfully and accurately and that any misrepresentations may result in denial of my Application for Admission to the Vets for Vets facility.

Date*

Entering your name in this field will act as your digital signature.*

*required field

If you prefer to print and submit the Admission Application, please click here to view the application.