All-Terrain Track Chair Application

*ALL-TERRAIN TRACK CHAIR APPLICATION
*ALL INFORMATION PROVIDED WILL BE TREATED AS PRIVATE IAW WITH HIPPA*

Name * First Last
Gender * Male Female
Date of Birth *
Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Alternate Phone - (###) - ### ####
Mobile Phone - (###) - ### ####
Email Address *
Alternate Email
Occupation/Title/Rank *
Marital Status *
Media Willingness * Yes No
Alternate/Emergency Contact *
Relationship to Emergency Contact *
Emergency Contact Phone * - (###) - ### ####
Service * Military Police EMS Firefighter
If Military Selected Above, Please Indicate Branch of Service
Service Status * Active Medically Retired Retired Other
If you selected Other above, please explain
Date of Injury *
Location of Injury (IRAQ, AFGHANISTAN, STATESIDE, OTHER) *
Type of Injury/Disability *
Are You Receiving Inpatient/Outpatient Care? * Yes No
Name and Location of Treatment Facility (If Yes above)
Name of Current Physician and Contact Information
Date of Last Treatment or Next Scheduled Visit
Type of Injury * Amputee Visually Impaired PTSD Spinal Cord Injury Shell Fragment Wound/Gunshot Wound TBI Other
If Other Selected above, please indicate
Injury Description *
PLEASE PROVIDE A SHORT ESSAY AS TO WHY YOU SHOULD BE SELECTED TO RECEIVE AN ALL TERRAIN TRACK CHAIR *
How did you hear about Wings for Our Heroes? * Newspaper Website Fellow Warrior Internet Friend/Relative Other
If Other selected above, please list here
*YOUR DIGITAL SIGNATURE BELOW ACKNOWLEDGES 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.
Your Full Name Here Serving As Your Digital Signature *
Type the letters you see in the image below.

All-Terrain Track Chair Application

All-Terrain Track Chair Application

*YOUR DIGITAL SIGNATURE BELOW ACKNOWLEDGES 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.