Enlistee/Recruiter Request Form

Personal Information:

Date

Month

Day

Year

First name

Last name

Birthday

Month

Day

Year

Mobile Phone

Alt. Phone (H/W):

Multi-line address

Country/Region

Address

City

Zip / Postal code

Last 4 digits of SSN:

Driver's License #:

Driver's License Expiration Date:

Month

Day

Year

What is your monthly income?

What are your monthly expenses?

Enlistee/Recruiter Information:

Recruiter/Office:

What branch of service are you in?

Contract Signed?

Ship Out Date:

Month

Day

Year

Location of Bootcamp:

Fitness Level Assessment (Special Warfare Recruits ONLY)

What is your 1 mile run time?

How many pull-ups in 2 min?

How many sit ups in 2 min?

What is your 500m swim time?

CAS swim time needed?

What is your fitness plan?

Additional 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 have pets?

Do you use alcohol or drugs?

Do you smoke/vape/chew?

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.

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