Wounded Warriors Family Support

Veteran Welding Training Program

* First Name

* Last Name

* Email

* Address

* City

* State

* Postal Code

* Phone

Military Information

* Service

* Component

* Pay Grade

* Number of Dependents

* Name & Age of Dependents

* Are the dependent children registered in DEERS?

* Are you medically discharged for wounds or injuries sustained in combat operations?

* Did your injuries or wounds occur during OIF/OEF?

Briefly describe your injuries and if you require special services due to your injuries.

* Do you require ADA compliant accommodations?

* Have you been awarded the Purple Heart?

* Have you participated in one of our programs in the past?

* Please describe how you plan to use the training provided

If you are currently in a WTU, what state is your home residence?

* What brought you to the site today?

Documentation

We require your DD214 to process your application. PDF or DOC formats.

Document

Purple Heart, DOD, or VA disability breakdown.

Other

If you have any issues attaching your documentation please contact us for assistance. You may also fax these documents to 402-916-4399

Application will not be processed without above documents.

By submitting this form, I authorize Wounded Warriors Family Support to review the attached documents that do contain information protected by the Health Insurance Portability and Accountability Act (HIPAA) for the use of this application and associated services. I agree that I am legally allowed to disclose the documents provided. I understand and agree that Wounded Warriors Family Support is not legally obligated to fulfill my request(s). I also agree that this release will apply to any and all future requests for support from Wounded Warriors Family Support, verbal or otherwise.

We do require you to submit your DD214 & Purple Heart, DOD, or VA Disability Breakdown. These documents may be uploaded at the bottom of this form or faxed to 402-916-4399

For more information about the program,

call Martin Duarte at 760-405-7777

E-mail: martin.duarte@wwfs.org