BRC Profile

Warrior Information

Full Name *

Gender *

Female

Male

Date of birth *

Address

City

State *

Postal code

Phone *

Email *

Warrior Occupation

Emergency Contact Information

Emergency Contact *

Relationship to Warrior

Emergency Contact Number *

Warrior Service Information

Branch of Service *

Air Force
Army
Coast Guard
LEO/First Responder
Marine Corps
Navy
Space Force
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MOS *

Discharge Status

Select One

Honorable
Dishonorable
Medical
Other than honorable
General
Entry level separation
Bad behavior
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Upload photo (DD214/Letter of Employment) *

Requested Clinic Date

Jan 16-17 2026
Jun 12- 13 2026
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