Bubble For Vets Application for Assistance
Thank you for reaching out to us! We appreciate your willingness to take this step. We will discuss your application and get back to you as soon as we are able. We have full-time jobs and do this because we want to
make a difference in others' lives. This means it may take a little more time than you might expect, but we look deeply at each person applying. Thank you, and we’ll talk to you soon.

If your application meets our criteria for assistance, here's what you can expect from us in the near future:
  • Notification of selection
  • Request for your VA disability rating document
  • Signed release forms for working with us (upon approval – this comes later)
Disclaimer: this information will be used to assess matching criteria with the mission of Bubbles for Vets. The information in this form will not be disclosed to anyone outside of Bubbles for Vets or shared with outside entities. The information provided in this form is completely voluntary and not essential but absence of information may prevent us from making a fully-informed determination for assisting you and your family.
Email *
First Name *
Last Name *
Phone Number *
Format:  xxx-xxx-xxxx
Email Address *
Home Address *
Branch of Service *
When did you exit the service? *
Select the 1st of the month if you cannot remember the specific date of your last day in the service.  If you are still Active Duty, Reserves, or National Guard, please leave this blank.
MM
/
DD
/
YYYY
Please select the characteristics of your family connection (Select all that apply)
 *
Required
Age of each child
What categories of challenge(s) are you working on overcoming or seeking help in dealing with? (select all that apply)
 *
Required
What is your highest level of scuba diving experience (Select all that apply)
 *
Required
Please select the physical disability you have (Select all that apply). 
 *
Note: all information provided is protected by HIPAA regulations and will not be shared with anyone or anywhere outside the Bubbles for Vets staff.
Required
Please describe the characteristics of your emotional/impulse control situation (Select all that apply).
 *
Note: all information provided is protected by HIPAA regulations and will not be shared with anyone or anywhere outside the Bubbles for Vets staff.
Required
Describe your goals in regaining or finding focus.
 *
Describe your goals in developing self-control.
 *
Describe what actions you have taken for improving your family connections.
 *
Describe what actions you have taken for improving your emotional/impulse control.
 *
Describe what accommodations are needed for you or your family's physical disabilities.
 *
Please write a short paragraph describing how you and your family have been impacted by your service and, and how you think bubbles could help rise above yours and the family's current challenges.
 *
Submit
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