Application to Attend a Retreat Heroes Renewal Center Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Service Status*ActiveVeteranService Dates*Please provide copy(ies) of DD214. Drop files here or Current or Former Rank*Air ForceArmyMarinesNavyCoast GuardNational Guard (Branch)Reserves (Branch)If you are actively serving, please list your current unit of assignment:First RespondersAre you currently servicing as a Law Enforcement Officer or Fire Fighter?YesNoIf so, list agency, rank, and time in service:* Military / VeteransDid you serve in a combat zone(s)?YesNoIf so, where and when?*Have you been diagnosed with, experienced symptoms of, or been treated for post-traumatic stress (PTSD)?YesNoIf so, what is your rating and by whom were you diagnosed?*Are you currently in treatment/therapy/counseling?YesNoIf 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.?YesNoIf 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?YesNoWill this dog be accompanying you to the retreat?*YesNoDid the trauma occur during your military service?YesNoIf not, under what circumstances did it occur?*Have you have been diagnosed with, experienced symptoms of, or been treated for traumatic brain injury (TBI)?YesNoIf so, by whom and where?*AllergiesMedications and FoodsAre there medical conditions, allergies (including food allergies) or medications of which we should be aware?*YesNoIf 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?*YesNoIf so, has it been within the last six (6) months?*YesNoIf you have a history of alcohol and/or drug dependence, are you currently clean and sober?YesNoIf 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.* Brochure Posted Flyer Website Veterans Helping Veterans Group Veterans Organization VA Vet Center A Veteran A Law Enforcement Officer or Fire Fighter Other, including referral If other, please identify:*Task Force Heroes Agreement PolicyTASK 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Important NoticeThis 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 StatementConsumer 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.CommentsThis field is for validation purposes and should be left unchanged. 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