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




MILITARY MEMBER'S PERSONAL INFORMATION














BACKGROUND INFORMATION

















HEALTH AND WELLNESS INFORMATION

If you are not seeking services for one or more of these concerns, please do not submit this application.























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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