Registration Form
Please take some time to read each question of the SemperMax Caregiver Retreat application and fill out the fields thouroughly and honestly. Applications will be reviewed and are not a guarantee of participation. Space is limited. After submission of this form, you will be contacted for any further information that may be needed. Remember, your name must match your photo ID! If you go by a different name, please share that in the comments field. Note: For a successful retreat, SEMPERMAX works with partner organizations. By sumbitting this form, you are allowing details of your application to be shared with those partners in order to best serve you.

* indicates required fields 
  *First/MI/Last Name of Warrior:
  *Phone #:
  *First/MI/Last Name of Caregiver:
  *Phone #:
  *Your Address:
  *Travel Preference:  Travel Preference
  *Preferred Airport:
  Second Airport Option:
  *Briefly describe warrior's injuries:
  *Warrior's level of TBI?:  No TBI
 3-Moderate TBI (Concussion)
 2-Medium TBI (Skull damage, but no penetratio
 3-Severe TBI (Skull penetration)
  *Click on those that apply:  Wheelchair?
 Service Dog?
 Food Allergies?
  *Warrior's Service:  Served in no military service.
 Coast Guard
 Air Force
  *To where has Warrior deployed?:  Never deployed outside of the US.
 Bosnia and/or Herzegovina
 Before 9/11
 Not on this list!
  *If deployed, was it a combat tour?:  No
  *Is Warrior a Purple Heart recipient?:  No
  *Warrior's Current Military Status:  Current Status
 Medically Retired
 Honorably Retired
 Honorably Discharged
 On Active Duty
 In a Reserve Status
  Special Needs/Considerations (i.e. minimal stairs):
  *What retreats have you been on before?:
  *What is Caregiver's greatest concern/challenge?:

After filling the details click on the SUBMIT button.




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