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Our Heroes’ Dreams

First Name

Last Name

Middle Initial

Gender
malefemale

DOB

Marital Status

Children

Occupation

Street Address

City

State

Zip Code

Please list prior occupations

Phone

Email

Branch of Service

Rank

Military Occupational Specialty

Are You Still on Active Duty?
yesno

What is your planned ETS date?

Did You Receive an Honorable Discharge?
yesno

Discharge Date (if applicable)

Was/Were Your Injury(ies) a Result of
CombatAccidentIllness

Date of Injury

Did You Receive a Purple Heart?
yesno

Is Your Injury
PermanentTemporary

What is Your VA Disability Rating?

What is Your Military Disability Rating?

Can You Provide Proof of Your Injury if Needed?
yesno

Military Medals Awarded

Circumstances Surrounding Your Injury(ies)

Types of Injury(ies) - Please be Specific

Medications Currently Taking: Prescribed and Non-Prescribed

Any Addictions or Allergies?

Legal Convictions (felonies or misdemeanors) or Issues? Please be Specific

Tell Us About Yourself

Interests or Hobbies - Please List

Interests Before Combat - Please List

Other Information You Feel May Be Important

Names and Ages of Family Members - Please List

In What Areas Are You Looking for Help?

How Did You Hear About OHD?