2012 Rehabilitation Institute of Chicago Winter Military Sports Camp

 

1. Name:

Name:

2. Date Of Birth:

Date Of Birth:

3. Gender:

Gender:   Male

Female

4. Address:

Address:

5. City:

City:

6. State:

State:

7. Zip Code:

Zip Code:

8. Cell Phone:

Cell Phone:

9. Alt. Phone:

Alt. Phone:

10. Email:

Email:

11. T Shirt Size:

T Shirt Size:   Small Medium

Large X Large

XX- Large XXX- Large

12. Branch of Service:

Branch of Service:   Army Marine Corps

Navy Air Force

Coast Guard

13. Dates of Service:

Dates of Service:

14. Rank:

Rank:

15. VA Affiliation:

VA Affiliation:

16. Active Duty Affiliation/WTU:

Active Duty Affiliation/WTU:

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

Have You Participated in Other Trips for Injured Military:   YES

NO

18. How many:

How many:

19. Please list trips/camps:

Please list trips/camps: