Veteran Registration Form - Peninsula Special Interest Lions Club, Inc.

Name*
First Last
Gender*
- Male
- Female
Social Security or Military ID Number*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Emergency Contact
First Last
Emergency Contact Relationship
Emergency Contact Phone
Have you attended a Stand Down before?*
- Yes
- No
If yes, where and when?
Marital Status*
- Married
- Widowed
- Divorced
- Separated
- Never Married
Employment Information*
- Employed
- Unemployed
- Retired
- Disabled
Are you receiving any income*
- Yes
- No
What do you believe is limiting your ability to become employed?*
- Education
- Experience
- Disability
- Transportation
- Criminal Record
- Child Care
- Drug Use
- Other
*Other Reason
Ethnicity*
- African American
- Asian American
- Native American
- Hispanic
- Caucasian
- Other
*Other Ethnicity
Housing*
- Homeless
- Living in a Shelter
- Renting
- Homeowner
- On the verge of becoming homeless
- Living with a Friend/Relative
- Living in transitional housing
If homeless, how long have you been homeless*
- 0-6 months
- 6-12 months
- 1-2 years
- 2-5 years
- 5+ years
Branch of Service*
Entry Date
Date Format: MM slash DD slash YYYY
Discharge Date
Date Format: MM slash DD slash YYYY
Discharge*
- Honorable
- Other than Honorable
- Dishonorable Bad Conduct/ General Court Martial
- Don't Know
Combat Theater / Service Era (Check as many as apply)*
- Peacetime 01/01/1947 06/26/1950
- Korea 06/27/1950 01/31/1955
- Peacetime 02/01/1955 08/04/1964
- Vietnam 08/05/1964 05/07/1975
- Peacetime 05/08/1975 08/01/1990
- Desert Shield/Storm 08/02/1990 09/10/2001
- OIF/OEF/OND 09/11/2001 Present
- Other Panama, Granada, Somalia, former Yugoslavia/Kosovo
Are you currently enrolled in VA Healthcare*
- Yes
- No
If no, why
Which of the follWhich of the following VA benefits have you received or claimed. Please check all that apply*
- Education GI Bill, Post 9/11, GI Bill etc...
- Service Connected Disability Compensation
- Medical or Dental Care
- HUD/VASH
- Vocational Rehabilitation & Employment
- Pension
- Home Loan
- VRAP
- None
- Other
Other services you would like to see at the next Stand Down. Check all that apply.
- Health Services
- Substance Abuse Services
- Legal Services
- Housing Assistance
- Mental Health Services
- Employment Assistance
- Veterans Benefits Counseling
Other Desired Services
Release of Information (ROI) signed*
- Yes
- No
Media Authorization Signed*
- Yes
- No
DD214#*
How did you hear about our Stand Down
Name
This field is for validation purposes and should be left unchanged.