Veterans Care Network Scholarship Application Question Title * 1. What branch of the military did you serve in? Army Navy Marines Air Force Coast Guard Other (please specify) OK Question Title * 2. What is your DD214 discharge status? Please know that we are considering veterans with any discharge status; this is not a disqualifier for our scholarship program. Honorable Other than Honorable Dishonorable General Bad Conduct Discharge Officer Discharge Entry Level Separation OK Question Title * 3. Are you willing to share a copy of your DD214 with Veterans Care Network for purposes of verifying your military and discharge status within 30 days of submitting this application? If so, please email it to email@example.com. Yes No OK Question Title * 4. When was the last time you were treated by a doctor, either in a primary care, urgent or emergency room setting? Within the last month 2-6 months ago 7-12 months ago Over 1 year ago OK Question Title * 5. Are you willing to participate in both pre and post program evaluations to determine personal success during the program? Yes No OK Question Title * 6. Are you willing to obtain medical services (at no cost to you) from a Veterans Care Network provider within the Detroit area to include lab work, physical evaluations and medication administration when needed at least every 2 months for a period no greater than 6 months? Yes No OK Question Title * 7. Would you need transportation in order to receive medical services within this program? Please know that your answer will not disqualify you in any way from being considered for this scholarship program. Yes No OK Question Title * 8. Are you willing to sign a medical release to Veterans Care Network providing us access to use medical data collected through this program for purposes of future planning, programming and evaluation? Yes No OK Question Title * 9. Are you willing to sign a release to participate in social media posts, photos, press releases, and any other marketing avenues in order for Veterans Care Network to share this program and its successes with the public in consideration for future programming, marketing and funding opportunities? Yes No OK Question Title * 10. Please provide the following information so that we may contact you further if selected for the program. Name Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number OK I HAVE COMPLETED MY APPLICATION, THANK YOU FOR CONSIDERATION.