Personal Interest Form

If you are interested in learning more about the Healthy Minds Healthy Bodies fitness initiative for military personnel who have returned home with disabilities, please complete and submit this Personal Interest Form.

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First Name: Last Name: Date of Birth: Street Address: City: County: State: Zip Code: Phone Number:  Enter a valid phone number. Example: 123-456-7890 Email Address:  Enter a valid email address. Example: name@company.com Did you receive a discharge under honorable conditions? Yes No Can you provide verification of honorable discharge and 10% or more disability? Yes No Branch of the military in which you served? Current or Last Rank? Were you injured during active duty? Yes No Description of Primary Disability: How did you hear about this program? What do you hope to get out of this program? Did you serve in the Iraq and/or Afghanistan War? Yes No