Healthy Minds Healthy Bodies Personal Interest Form

2. If you are interested in learning more about the Healthy Minds Healthy Bodies fitness initiative for military personnel who have returned home with disabilities, please complete and submit this Personal Interest Form.

4. First Name*

5. Last Name*

7. Gender*
   -- Select One --FemaleMale

8. Date of Birth*
   Date of Birth

10. Phone Number*

11. Email Address*

13. Driver License Number*

15. Street Address*

17. City*

18. State*

19. Zip*

21. County*

23. Did you receive a discharge under honorable conditions? *

    1. Yes
    2. No

25. Can you provide verification of honorable discharge and 10% or more disability?

    1. Yes
    2. No

    Prince George's County Department of Parks and Recreation does not keep these documents on file. Documentation must be presented for visual verification only.

27. Dates of Service*
    Dates of Service Start Date

    —

    Dates of Service End Date

28. Branch of the military in which you served*

30. Were you injured during active duty? *

    1. Yes
    2. No

32. Description of Primary Disability*

34. How did you hear about this program?*

36. Which facility would you like to host your membership?*
    -- Select One --Fairland Sports and Aquatics ComplexPrince George's Sports and Learning ComplexSouthern Area Aquatics & Recreation Complex

38. Adult Shirt Size

40. Gender*
    -- Select One --FemaleMale

41. Size*
    -- Select One --Extra SmallSmallMediumLargeExtra LargeDouble Extra LargeTriple Extra Large

Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field