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Veterans Bridge Home Newsletter Registration

Please fill out the following to get on our distro list and get connected.

1.First Name(Required.)
2.Last Name(Required.)
3.Status
4.Date of Birth (mm/dd/yy)
5.Gender
6.Branch of Service
7.Rank at Exit
8.Service Start Date (mm/dd/yy)
9.Service End Date (mm/dd/yy)
10.At what email address would you like to be contacted?(Required.)
11.Phone Number(Required.)
12.Preferred Contact Method(Required.)
13.How did you hear about Veterans Bridge Home?
14.I am interested in learning more about:
15.NCServes consent.

We thank you for requesting assistance from the first ever coordinated network of providers
serving Veterans and Military Families. By requesting assistance from an organization within the
network (named NCServes), you will have access to a plethora of public and private
organizations that can assist with a multitude of services. In doing so, the network will work
together to service your needs in the most efficient way.

I give my permission for enrollment into programs with services and or training which may be funded by
a local, state or federal department or agency. I have been informed that these funding sources may
verify service activities reported by the NCServes Coordination Center in order to comply with these
requirements.
By agreeing to this consent and authorization form, you authorize your information to be inputted into a
digital referral system. In doing so, you will not hold liable any parties involved in the network, or the
internet and website provider.