2012 Rehabilitation Institute of Chicago Winter Military Sports Camp

Service Personnel Information

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* 1. Name:

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* 2. Date Of Birth:

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* 3. Gender:

Male

Female

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* 4. Address:

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* 5. City:

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* 6. State:

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* 7. Zip Code:

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* 8. Cell Phone:

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* 9. Alt. Phone:

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* 10. Email:

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* 11. T Shirt Size:

Small

Medium

Large

X Large

XX- Large

XXX- Large

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* 12. Branch of Service:

Army

Marine Corps

Navy

Air Force

Coast Guard

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* 13. Dates of Service:

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* 14. Rank:

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* 15. VA Affiliation:

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* 16. Active Duty Affiliation/WTU:

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* 17. Have You Participated in Other Trips for Injured Military:

YES

NO

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* 18. How many:

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* 19. Please list trips/camps: