Registration

First Name: Last Name: Gender: Female Male Birth Date (MM/DD/YYYY): / / Participant Category: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavat Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Phone: Email: Emergency Contact Name (Relationship) Emergency Phone and/or Email Allergies: Medications: Seizure History: No Yes Date of Last Seizure: Diabetes History: No Yes How is diabetes controlled: Height: Weight: Service Animal: No Yes Service Animal Name: Disability: Disability "Other" Description: Mobility Program Interest: How did you find out about the program? Veteran / Active Military Service No Yes Eligible for VA Services and Not Barred No Yes Branch of Service Rank Date of Injury Service Connected Disability Yes No Served Post-911 No Yes Home VA Occupation Volunteer Skills Trainings/Skills/Experience/Certifications Ethnicity Hispanic or Latino Not Hispanic or Latino Race Create a Login Name: Password: Retype Password: