2022 HTW Participant Registration Form
This form is for women veterans, and daughters (ages 18-25) of veterans, interested in attending the HerTOTALWellness program. You must be a resident of Florida to participate. Proof of military service and Florida residency is required.

Contact Program Coordinator, Sanya Mackenzie, for questions on her work cell phone at (904) 201-9183 or email htw@forwomenvets.org.
E-post *
Before proceeding, please be sure you have your DD214 and current (not expired) Government-issued photo ID or military ID. If you do not have your DD214, a recent official VA letter showing your veteran status will suffice. If your name is different from that on your military record and your photo ID, a legal name change document must also be submitted. For daughters (ages 18-25), you must have access to your parent's DD214 or recent official VA letter showing the veteran's status and any legal name change documents, along with your Government-issued photo ID. You may email your documents to the Program Coordinator, Sanya Mackenzie, at htw@forwomenvets.org. Please black out your social security number before sending your documents online. You can also opt to drop a copy of your documents off in person at, or mail them to, Northeast Florida Women Veterans, Attn: Sanya Mackenzie, 103 Century 21 Drive, Suite 201, Jacksonville, FL 32216.
First & Last Name as it appears on your Driver License or other Government-issued ID (If your name does not match that on your DD214 or official VA letter, a legal name change document must be submitted) *
Birth Date: *
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Last 4 numbers of your Social Security *
Cell Phone Number (include area code) *
May we text you on your cell phone? *
Home Phone/2nd Cell Phone Number  (include area code)
Best email to reach you at *
Physical Address *
In which Florida county do you reside? *
Mailing Address *
Which Cohort are you registering for? *
Please note the schedule may be subject to change due to unforeseen circumstances. If this happens, you will be notified with as much notice as possible. If selected for a Cohort, please review the schedule and add the dates to your calendar to ensure you are present on each day. Classes are currently held in our office, located at 103 Century 21 Drive, Suite 201, Jacksonville, FL 32216, on Tuesdays and Thursdays from 9:00 am to 1:00 pm but may be subject to change. Graduation ceremonies are held on Fridays at 10:00 am.
I have reviewed my calendar and confirm that I am available to attend classes on Tuesdays and Thursdays, from 9 am to 1 pm, for the Cohort and schedule selected above. *
Which Branch of Service were you enlisted in? *
Obligatorisk
Which Component of Service were you in?
Discharge Type:
Rensa markering
Entry Date:
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Discharge Date:
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 Are You a Combat Vet? *
Did you serve Post 9/11 *
VA Disability Rating %
Tee-Shirt Size (T-Shirts will be issued upon completion of the program) *
How  Did You Hear About Us: *
Employment *
Obligatorisk
Level of Education *
Emergency Contact Name (Please list someone who lives near you) *
Emergency Contact Phone Number  (include area code) *
Emergency Contact Address
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