Program Application

Battleworn Foundation exists to serve military members and first responders by forging authentic brotherhood, and equipping

men, women and their families through Christ-centered resiliency programs that cultivate hope, restoration and a lasting legacy.

Application Purpose

This application is intended for military members, veterans, first responders, qualifying spouses, and family members seeking

participation, assistance, or scholarship support through Battleworn Foundation programs.

Eligibility Review

Applications are reviewed on a case-by-case basis. Submission does not guarantee acceptance, scholarship funding, travel

assistance, or program placement. Battleworn Foundation may request additional information to verify eligibility and ensure

proper care.

Preferred Program / Support Requested

Date Submitted

First Name *

Middle

Last Name *

Address *

Street Address

City

State

Country

Postal Code

Email Address *

Phone *

Confirm Phone Number and make sure the number is different from your spouse’s number. (OUR SYSTEM WILL NOT ALLOW PHONE NUMBERS USED IN PREVIOUS APPLICATIONS).

What is the best way to contact you? 117ek

Phone

Text

Any of the above

Nearest Major Airport / Travel Hub *

What is the city of this airport?

What is the state of this airport?

Have you previously applied for or attended a Battleworn program?

Yes

If yes, please explain when, where, and under what program

Date of birth *

Gender at Birth 11fsa *

Male

Female

Marital Status *

Any Religious Affiliation

N/A if none

Height

Weight

T-Shirt Size

Spouse Name

Spouse Phone / Email

Children / Dependent

Briefly describe your current family situation and any support needs:

What do you hope Battleworn Foundation can help cultivate in your life or family?

What program are you interested in?

How soon would you like/be able to attend

Please select an option that would match your availability.

Preferred Location / Region

What would you like to get out of our program?

Emergency Contact First Name *

Emergency Contact Last Name *

Relationship *

Emergency Contact Phone Number

Email Address (Emergency)

Alternate Phone (Emergency)

Address / City / State

Anything Battleworn Foundation should know about contacting this person in an emergency

Name (Second)

Relationship (Second)

Phone (Second)

Current medications (If none, please write "None.") *

(For medical emergency purposes only, if none, please annotate 'None'.)

Current medical issues, injuries, conditions, or limitations *

(i.e. PTSD, Depression, Anxiety, Seizures, etc.) Please explain.

Will you be attending the program with any of the following?

Wheelchair

Crutch or Prosthesis

Service dog

N/A

Are you on a doctor-prescribed diet?

Yes

Food Allergies * (If none, please write "None.")

Medication Allergies * (If none, please write "None.")

Prescription eyewear used: *

Glasses

Contact lenses

None

Will you require assistance with dressing, bathing, eating, mobility, travel, or other basic needs?

i.e. Dressing, Bathing, Eating, etc.

Terms *

I have read and understand the terms above. *

I affirm that the information provided is accurate and complete. *

I authorize Battleworn Foundation to contact me regarding this application and related next steps. *

I understand medical information is requested for participant care, safety, and emergency planning. *

Travel Assistance Request: If applicable, explain airfare, mileage, lodging, or other transportation

Full Legal Name as it appears on Government ID *

Please provide the name as it appears on your Federal / State Government Issued ID, i.e. Drivers License, State ID, Retired Military, etc. (Include Middle Name or Middle Initial)

Signature *

Clear

Date

Reviewer / Internal Notes

Application Checklist

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