Healing Journey Registration – Healing Through Reckoning and Responsibility

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Occupation or Profession

Email *

Gender *

Birthdate mm/dd/yyyy

Emergency Contact *

First

Last

Emergency Contact Phone *

Are you... (check all that apply) *

Rank

Branch of Service

Area of Operation

Time of Service

Have you been in combat?

Yes
No

Where have you been in combat?

Have you experienced (check all that apply)

Military Sexual Trauma (MST)
Traumatic Brain Injury (TBI)

Have you worked with the military?

Yes
No

In what capacity have you worked with the military?

Do you have any food restrictions or disability restrictions affecting your room or special needs? *

Yes
No

Please list any special needs

Any questions?

Any other information you feel we should know?

Please enter first name only of spouses, children, parents, or close family and their relationship to you for use in one of the rituals. None will be contacted in any way.

Room Preference *

Single Room - $700
Double Room - $600

Preferred Roommate

Will you be applying for a complete or partial scholarship?

Yes
No

(Final determination will be made following the interview process.)

Single Line Text

Email *

Multiple Items

Single Room
Double Room
Donation

Total

$ 0.00

Email *