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*THIS IS NOT A FINANCIAL ASSISTANCE/FINANCIAL RELIEF OR CRISIS-CENTERED PROGRAM*
SUBMITTER'S INFORMATION



INITIAL PROGRAM QUALIFICATION

*If no is selected above, please do not continue with this form
QUALIFICATION RESULT
Based on the response provided, it does not appear that the Veteran qualifies for Boot Campaign Health and Wellness Program services at this time.

To address other needs, visit Patriot Link (https://www.patriotlink.org/) for a comprehensive and searchable database of veteran and military family resources.

Should you have additional questions, contact us here.
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.  
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NOTICE: 

Our team at Boot Campaign is working diligently to process the numerous applications for our health and wellness program, while also continuing to deliver the high-quality, individualized and life-improving care that we promise. We will send periodic updates via email and contact you personally when your pre-registration is being processed.
MILITARY MEMBER'S PERSONAL INFORMATION














BACKGROUND INFORMATION

















HEALTH AND WELLNESS INFORMATION


























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. 

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