SUDS Confidential Application

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Gender

Height

Weight

Phone

Branch of Service and Rank

Did you serve in Iraq or Afghanistan?

Yes

Was your injury combat-related?

Yes

Date of Injury

Current Medications

Injury/Disability & any limitations: (Medical History)

Current Passport?

Yes

Emergency contact / Name, Relation & Cell number:

Place of employment or name of university/college currently attending:

Commitment: A considerable amount of time, effort & money goes into this program to make it successful. We have ZERO tolerance for illegal drugs, alcohol abuse, sexual harassment, physical and/or emotional abuse. Also, the use of medical marijuana on a SUDS trip is a disqualifier for participation. Failure to follow these policies could result in your discharge from the program. Filling out this application does not guarantee placement into the SUDS program.

Are you 100% committed to attend this program

Yes

Briefly describe your current fitness level?

Please tell us a little bit about yourself.

Why do you want to participate in this program?

This field is for validation purposes and should be left unchanged.