Application to Attend a Retreat ‹ Task Force Heroes

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email*

Service Status*

Active
Veteran

Service Dates*

Please provide copy(ies) of DD214.

Drop files here or

Current or Former Rank*

Air Force

Army

Marines

Navy

Coast Guard

National Guard (Branch)

Reserves (Branch)

If you are actively serving, please list your current unit of assignment:

First Responders

Are you currently servicing as a Law Enforcement Officer or Fire Fighter?

Yes
No

If so, list agency, rank, and time in service:*

Military / Veterans

Did you serve in a combat zone(s)?

Yes
No

If so, where and when?*

Have you been diagnosed with, experienced symptoms of, or been treated for post-traumatic stress (PTSD)?

Yes
No

If so, what is your rating and by whom were you diagnosed?*

Are you currently in treatment/therapy/counseling?

Yes
No

If so, please provide name of provider (optional):

Are you taking any prescription medications for medical and/or mental health condition(s) such as PTSD, TBI, etc.?

Yes
No

If so, please list ALL medications and dosages that have been prescribed, including but not limited to, medical marijuana. This information will not be disclosed to other attendees and is limited only to TFH staff.*

Name & Dosage(s) of Medication

Do you have a service dog?

Yes
No

Will this dog be accompanying you to the retreat?*

Yes
No

Did the trauma occur during your military service?

Yes
No

If not, under what circumstances did it occur?*

Have you have been diagnosed with, experienced symptoms of, or been treated for traumatic brain injury (TBI)?

Yes
No

If so, by whom and where?*

Allergies

Medications and Foods

Are there medical conditions, allergies (including food allergies) or medications of which we should be aware?*

Yes
No

If so, please list:*

Medical Condition or Allergy Reaction

Medications*

(Please bring all required with you.)

What dietary restrictions, if any, do you have (gluten-free, vegetarian, vegan, etc.)?

Do you require special accommodations for any physical disability (ramps, grip bar for bathroom shower, etc.)?

Have you completed a treatment program for alcohol and/or drugs?*

Yes
No

If so, has it been within the last six (6) months?*

Yes
No

If you have a history of alcohol and/or drug dependence, are you currently clean and sober?

Yes
No

If so, for how long?*

What specifically would you like to gain from this retreat?*

How did you find out about these retreats? If none of those below, please identify.*

If other, please identify:*

Task Force Heroes Agreement Policy

TASK FORCE HEROES retreats are substance-free (other than prescribed medications) events. No weapons, alcohol or Illegal drugs are permitted to be brought to the retreats and by signing this application participants agree to these policies. By signing this application, I acknowledge and authorize representatives of TASK FORCE HEROES to discuss this application with any representative of a VETERANS ADMINISTRATION CENTER or other referral organizations or agencies. I agree to participate fully in this multi-day retreat. Additionally, I agree and understand that I attend this retreat at my own risk. Any injuries that occur to myself or anyone else are my responsibility and I do not hold TASK FORCE HEROES liable in any way. By signing this document I agree to the above mentioned policies and fully understand them.

Hero Signature*

Please type your name.

Date*

Important Notice

This retreat is FREE to participants. Once your application is received and processed, we will contact you. Applicants will be registered in the order in which their application is received. Application must be received 30 days prior to the retreat date in order to process.

Confidentiality Statement

Consumer confidentiality is governed by many laws and regulations. These include: HIPAA (regulations at 45 CFR Parts 160 and 164), the Federal law related to privacy of health information; Federal substance abuse law (regulations at 42 CFR Part 2); Montana State mental health confidentiality law (MCA-41-3-205; MCA 26-1-807) Federal protection and advocacy agency regulations (42 CFR Part 51); and State mental health confidentiality regulations (MCA/SEC of STATE 24.219.1211) If there is a clear and substantial reason to believe that a consumer poses an immediate danger of serious physical harm to him/herself or others, providers must notify any person (including law enforcement and the endangered person) who may reasonably be able to prevent or lessen the threat.

Comments

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