Enlistee/Recruiter Request Form
Driver's License Expiration Date:*
Enlistee/Recruiter Information:
Do you feel safe at home?
Do you belong to a gym or YMCA?
Do you receive public assistance?
Do you have family support?
Are you familiar with your local food shelf?
Do you have a local church?
Do you have a social worker?
Do you use alcohol or drugs?
Have you ever received or applied for help from Revitalizing Veterans' Dreams?
Please read and sign below:
Failure to report for PST (physical fitness tests) can terminate additional help from Revitalizing Veterans' Dreams. I understand that signing my name below releases my personal information. Information will only be used for application purposes, and will not be shared.
