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Survivor Outreach Services
Help Us Keep In Touch
Dear Survivor Families,
Please help us create and keep accurate records and maintain updated information. Thank you!
1.
Contact Information:
Name
Mailing Address
City
State
zip Code
Phone Number (Home)
Phone Number (Cell)
Phone Number (Work)
Email Address
Name and Rank of Fallen Hero
2.
Preferred method of contact
E-mail
Phone
U.S. Mail
3.
Please check all that apply:
I would like someone to call me in regards to my emotional well being
I would like to speak with another Survivor Family
I would like to be involved in a Grief Support Group in my area
I would like to be contacted regarding financial counseling/planning
I have questions about wills and or life insurance
Would you like to speak to a Financial Counselor?
Do you need a Survivor Outreach Services decal for your vehicle?
What programs would you like to see SOS offer to better support you:
4.
Mark the items that interest you:
I would like information about:
Child care
Support Groups or counseling for
Medical care
Dental Care
Employment
Financial Counseling
Meeting with other survivor parents
Meeting with other survivor wives
Meeting with other survivor husbands
Meeting with other survivor siblings
Meeting with SOS staff and Families regularly
What does my community offer to Survivor Families
5.
If you checked off meeting with SOS staff and Families regularly, How often? and How far are you willing to travel to attend these meetings?
Once a month
One every 3 months
Twice a year
Travel 30 minutes or less
Travel 1 to 2 hours
Travel 3 hours or more
6.
I would like resources on the topic(s) of:
7.
Suggestions or general comments:
8.
Tammie Conner
PH# 802 338 3398
tammie.l.conner.ctr@mail.mil
9.
PRIVACY STATEMENT:
Principle Purpose: to create, update and maintain SOS Client Information.
Routine uses: To enhance Client contact capabilities. To identify trends for projecting future programs and activities.
Disclosure: Voluntary; however, if not provided, client support may be limited by incomplete or incorrect information already on file.
