All-terrain Chair Application

ALL INFORMATION PROVIDED WILL BE TREATED AS PRIVATE LAW WITH HIPPA

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Name *

First

Last

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Gender *

• Male
• Female

Date of Birth *

Mailing Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

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Primary Phone Number *

Alternative Phone Number

Email Address *

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Marital Status *SingleMarriedWidowedDivorced/Separated

Occupation/Title/Rank *

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Type of Service *

• Military
• Police/Corrections
• EMS
• Firefighter

Please Indicate Branch of Military Service *

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Service Status *

• Active
• Medically Retired
• Retired
• Other

Please explain "other" service status *

Type of Injury *

• Amputee
• Visually Impaired
• PTSD
• Spinal Cord Injury
• Shell Fragment Wound/Gunshot Wound
• TBI
• Other

If Other selected above, please indicate *

Injury/Disability Description *

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Date of Injury/Disability *

Location of Injury/Disability *

(IRAQ, AFGHANISTAN, STATESIDE, OTHER)

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Are You Receiving Inpatient/Outpatient Care? *

• Yes
• No

Name and Location of Treatment Facility *

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Name of Current Physician and Contact Information *

Date of Last Treatment or Next Scheduled Visit *

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Alternate/Emergency Contact *

Relationship to Emergency Contact *

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Emergency Contact Phone *

Are you willing to participate in Wings for Our Heroes media/press?

• Yes
• No

Please provide a short essay as to why you should be selected to receive an All-Terrain Track Chair: *

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How did you hear about Wings for Our Heroes? *

• Newspaper
• Website
• Fellow Warrior
• Internet
• Friend/Relative
• Other

If Other selected above, please list here *

BY CHECKING THE BOX BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD THIS APPLICATION. PICTURES, VIDEO AND ALL SOCIAL MEDIA WILL BE PERMITTED AND AT THE DISCRETION OF WINGS FOR OUR HEROES UNLESS OTHERWISE AGREED UPON. *

• I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THIS APPLICATION.

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