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Boot Campaign's Health & Wellness Program screening form includes some basic questions to help us direct you to the proper resources to suit your current needs.
 
*THIS IS NOT A FINANCIAL ASSISTANCE OR FINANCIAL RELIEF PROGRAM*
**CRISIS INFORMATION**
If you are experiencing a crisis and are contemplating suicide, immediately call the VETERANS CRISIS LINE at 1-800-273-8255 and press 1 or text 838255. You can also find more information at www.veteranscrisisline.net. If you are attempting suicide, or have committed bodily harm to yourself or others, please dial 911 immediately.  

If at the time of your application we are led to believe you are in a crisis situation we will immediately follow our crisis protocol.
MILITARY MEMBER'S PERSONAL INFORMATION












BACKGROUND INFORMATION









Check ALL that apply

CONFIRMATION


*Disclaimer: Boot Campaign does not discriminate on the basis of race, color, national origin, creed, 

marital status, sex, disability, age, gender identity, or sexual orientation in our organization's activities, 

including the grant process.