Application for First Responder Retreats

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form, verify its accuracy, and then click the Submit button. This information assists us in selecting participants who can successfully complete and benefit from this retreat and in planning appropriate activities. Your participation during the retreat will afford you the opportunity to engage in activities that are physically demanding and emotionally draining. It is important that you accurately complete this form to maximize the benefits of retreat.

By submitting this form, you are confirming that you have provided all the information that is requested and that you have no medical or other restrictions that you have not disclosed that would interfere with your participation.

After the review of the application, the PRLI reserves the right to request that you provide a release of information form to your physician or therapist so we can get confirmation that you are physically, emotionally and psychologically able to participate in a Camp Resilience session.

NOTE: The information provided in this application will be secured and only viewed by mental health professionals for screening purposes. It will not be released or shared with any other individuals or organizations.

Who referred you to Camp Resilience?

First Name *

Last Name *

Preferred Name *

Address

City *

State *

Zip Code *

Phone *

E-mail

Occupation *

Dates of Service

Date of Birth *

Height *

Weight *

Gender (for room assignments)

Female

Male

Clear selection

Are you a veteran? *

Yes

Required

List All Known Allergies *

Please list any dietary restrictions (allergies, gluten free, vegetarian etc.)

Have you been treated by a Physician/Therapist in the past 12 months? If yes, why? *

Check any medical/psychological conditions below that apply to you: *

Post Traumatic Stress

Traumatic Brain Injury

Anger, physical aggression

Paranoid thoughts

Migraine headaches

Severe hayfever

Respiratory problems

Back problems

Dizziness or fainting

Recent surgery

Alcohol or drug abuse (more than 4-5 drinks a day and/or the misuse of prescription, illegal or other substances)

Other:

Required

Remarks - explain any medical conditions checked above

Are you able to share a room with another attendee (same gender)? *

Yes, I am ok having a roommate

No, I would like a single room (this must be approved by your treating therapist/physician)

What else, if anything, should we know about you to support your participation in this program (example: "I fatigue easily and would appreciate opportunities to sit whenever possible", "I have limited use of my right arm", "I have sleep apnea") *

Briefly discuss anything that you are currently dealing with in regards to your position and how you think the "Armor Up" retreat will help you better deal with these issues. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms