Assistance Application

To be considered for the Camaraderie Foundation’s services, please complete the form below.

1. I am a:  Service Member Spouse Direct Relative


2. First Name* 3. Last Name*
 



4. Address*

5. City*   6. State*   7. Zipcode*   8. Phone Number*   9. Email Address*
       


10. Date of Birth*   11. Marital Status*
 


12. How many deployments have you, your spouse or your immediate family member
been on?


13. Are you, your spouse or immediate family member currently active in the military? 14. Employer
 Yes No


15. Have you pre-selected a counselor? If yes, list the person or practice
 Yes No


Counselor's Address

16. City   17. State   18. Zipcode   19. Phone Number
     


20. Do you or the service member you're inquiring about have children? If so, how many?
 Yes No


21. List the members of your family who may want counseling now or in the future.
Name   Age   Sex   Relationship
     
Name   Age   Sex   Relationship
     
Name   Age   Sex   Relationship
     
Name   Age   Sex   Relationship
     


22. Upload copy of current military I.D. or DD214


*indicates required field