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: *
Select oneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip / Postal Code:

Other Information:

Gender:
Select oneMaleFemale

Date of Birth:
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

Marital Status:
Select oneSingleMarriedEngagedDivorced

Spouse:

Dependents:
Select one012345+

Branch of Service:
Select oneUS Air ForceUS ArmyUS Coast GuardUS MarinesUS Navy

Level of Service:
Select oneActive DutyReserve DutyNational Guard

Medically Retired:
Select oneYesNo

Discharged:
Select oneYesNo

Date of Discharge:
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

OEF / OIF:
Select oneYesNo

Date of Injury:
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

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

If other, please describe:

Need Wheelchair:
Select oneYesNo

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?: *
Select oneYesNo

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

How were you referred?: