Request Assistance

Servicemember Information:

This application for assistance is not meant to be used in an immediate crisis or as an immediate intervention in an emergency. If this is an emergency or you or the person you are requesting assistance for are suicidal call 911, the National Suicide Prevention Lifeline at (800) 273-8255 (TALK) and press option 1 for the Military Crisis Line, or call your local emergency services provider.

Someone from The American Legion in your area will contact you soon using the information you provide. Please be sure to include the area code for phone numbers and an email address if possible.

First name: *

Last name: *

E-mail: *

Phone Number:

Location Where Assistance Is Requested:

Address:

City:

State: *

Zip / Postal Code:

Other Information:

Gender:

Date of Birth:

Marital Status:

Spouse:

Dependents:

Branch of Service:

Level of Service:

Medically Retired:

Discharged:

Date of Discharge:

OEF / OIF:

Date of Injury:

Injuries:
Amputation
TBI
Blindness
PTSD
Paralysis
Permanent Disfigurement
Severe Burns
Hospitalization
Multiple Surgeries
Hearing Loss
Other

If other, please describe:

Need Wheelchair:

DoD Disability Rating:

VA Disability Rating:

Special Requests for Assistance:
Adaptations to Home or Vehicle
Adaptive Sports
Homecoming Celebration
Housing Assistance
Government Claims Assistance
Temporary Financial Assistance
Transportation to Hospital Visits
Employment Assistance
Educational Assistance
Entertainment Options
Childcare
Counseling
Family Support
Military Treatment Facility
Veterans Affairs Medical Facility

Additional Information:

May we contact you for more information?: *

May we share your information in order to assist you?: *

How were you referred?: