Operation Heal Our Patriots Application

Encuentro con el amor sanador de Dios

This summer 170 military couples will be invited to experience a week of marriage enrichment at our lodge in wilderness Alaska. Apply now to be one of them!

Operation Heal Our Patriots gives wounded veterans and their spouses an opportunity to strengthen their marriage and find physical and spiritual refreshment. Couples enjoy the beauty of God’s creation and participate in Biblically based marriage classes that help build their relationship with each other and with Jesus Christ. Through our robust Family Care program, we continue to support participants long after their initial stay, keeping their spiritual needs and marriages a priority.

Before you begin filling out this application, be sure you have a digital photo of you and your spouse ready to attach, as well as your DD-214 (or service record, if you are active duty and spouse DD-214 if applicable). Applications cannot be submitted without both a photo and DD-214 attached. Please note: this application may not work properly with some older browsers and mobile devices. If you have technical difficulties, please call 828-278-1625.

Paso 1 de 8

Have you or your spouse ever participated in our marriage enrichment training at Samaritan Lodge Alaska?*
- Sí
- No
Operation Heal Our Patriots is honored to serve our veteran couples. To ensure we serve as many veteran couples as possible, alumni couples and/or remarried participants are only allowed one opportunity to participate in training at Samaritan Lodge Alaska.

Nombre del Veterano Herido

If both are veterans please use most qualified applicant based on post-9/11 service.
Apellido(s)*
Primer Nombre*
Segundo Nombre
Nombre Preferido
Fecha de nacimiento*
Month
Day
Year
Current Physical Address*
Calle Calle 2 Ciudad Estado Código postal

Is your mailing address the same as your physical address?*

Sí

No
Dirección de correo *
Calle Calle 2 Ciudad Estado Código postal

Cell Number*
Additional Contact Number
Correo electrónico*

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Service Details
Branch of Service*
Status*
Rank*
Military Service From Date*
Month
Day
Year
Military Service To Date*
Month
Day
Year
(If currently on active duty, use today's date.)
Number of Combat Deployments*
List of Combat Deployment(s)
Add DD-214*
Please attach your DD-214 or service record for active duty.
Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF. Please note: we do not use your Social Security number for any reason so please redact it.

Add file... Your file has not been uploaded.

Please attach any additional service documents (ex: combat citations, etc.).

Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF. Please note: we do not use your Social Security number for any reason so please redact it.

Add file... Your file has not been uploaded.

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Combat or Service Related Injury Date*
Month
Day
Year
Approximate date of injury if PTSD/TBI/cumulative musculoskeletal injury.
Please select one or more entries that best describe your injury/injuries.*
Did you receive a Purple Heart for your injury?

Sí

No
Please describe the incident for which you were awarded the Purple Heart.
Please provide a detailed description of your injury (or injuries), including how, and where your injuries occurred.*
Are you currently receiving medical treatment? If so, please describe, and include any special medical needs.
Operation Heal Our Patriots operates in a remote region of the Alaskan wilderness. Do you rely on any specialized medical equipment? If so, please describe. (eg. Wheelchair, prosthetics, CPAP)
Please provide a physical description of your injuries and limitations.

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Spouse Information:
Please enter your spouse's name exactly as it appears on their driver's license.
Spouse Last Name*
Spouse First Name*
Segundo Nombre
Nombre Preferido
Spouse Date of Birth*
Month
Day
Year
Is your physical address the same as your spouse?*

Sí

No
Current Physical Address*
Calle Calle 2 Ciudad Estado Código postal

Spouse Cell Number*
Spouse Additional Number
Spouse Email Address*

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Spouse Military Information
As the spouse of the primary applicant, are you also a post-9/11 veteran?*

Sí

No
Branch of Service*
Status*
Rank*
Military Service From Date*
Month
Day
Year
Military Service To Date*
Month
Day
Year
If currently on active duty, use today's date.
Number of Combat Deployments*
List of Combat Deployment(s)
Please attach a copy of your spouse DD-214 or service record for active duty.*
Please attach your DD-214 or service record for active duty.
Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF. Please note: we do not use your Social Security number for any reason so please redact it.

Add file... Your file has not been uploaded.

Please attach any additional spouse service documents (ex: combat citations, etc.).

Images should be no larger than 5MB, and may be in one of the following formats: JPG, GIF, or PDF. Please note: we do not use your Social Security number for any reason so please redact it.

Add file... Your file has not been uploaded.

Were you injured during post-9/11 military service?

Sí

No
Combat or Service Related Injury Date*
Month
Day
Year
Approximate date of injury if PTSD/TBI/cumulative musculoskeletal injury.
Please select one or more entries that best describe your injury/injuries.*
Did you receive a Purple Heart for your injury

Sí

No
Please describe the incident for which you were awarded the Purple Heart.
Please provide a detailed description of your injury (or injuries), including how, and where your injuries occurred.*
If no injuries, please list “none”
Are you currently receiving medical treatment? If so, please describe and include any special medical needs.
Operation Heal Our Patriots operates in a remote region of the Alaskan wilderness. Do you rely on any specialized medical equipment? If so, please describe.
Please provide a physical description of your injuries or limitations.

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Describe Your Marriage

Marital Status?*
Please describe your marriage and the reason for the marital status:*
Has military service/injuries affected your marriage? Please tell us how.
Why are you applying for Operation Heal Our Patriots and what do you hope to get out of participation?*
Do you have a faith background?*

Sí

No
Please describe your faith background.*
Does your support system include a church?*

Sí

No
Please provide the church name and address and briefly describe your level of involvement.*
List any marriage counseling/programs previously attended.
If you have been recommended by a previous Operation Heal Our Patriots participant, please provide their name.
How did you learn about Operation Heal Our Patriots?*
If there is a last minute cancellation would you be able to attend on a short notice (72 hours)?

Sí

No

To effectively deliver this program, Samaritan’s Purse, through Operation Heal Our Patriots, may collect, process, store, and/or disclose your personal data in accordance with our Política de privacidad.

Operation Heal Our Patriots cares deeply about protecting your personal information. Any injury information provided on this application will be used for the sole purpose of determining eligibility to the program and may be used by our staff in supporting you at Samaritan Lodge Alaska if you are selected for the program.

Operation Heal Our Patriots Consent:*
Yes, I consent to the limited use of my personal information as described above.
Comentarios
Este campo es un campo de validación y debe quedar sin cambios.

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Encuentro con el amor sanador de Dios

Paso 1 de 8

Note Program Requirements

Service Details

Spouse Military Information

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