Personal Interest Form

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.

First Name:
Last Name:
Gender:	Male Female
Date of Birth:	< November 2024 > Sun Mon Tue Wed Thu Fri Sat 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7
Street  Address: City, State, Zip	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS FM GU MH MP PW PR VI
County:
Telephone:
Email Address:
Did you receive a discharge under honorable conditions?	Yes   No
Can you provide verification of honorable discharge and 10% or more disability?	Yes No Note: Prince George's County Department of Parks and Recreation does not keep these documents on file. Documentation must be presented for visual verification ONLY.
Provide dates of service:
Branch of the military in which you served:
Were you injured during active duty?	Yes No
Description of Primary Disability:
How did you hear about this program?
Which facility would you like to host your membership?	Fairland Sports and Aquatics Complex Prince George's Sports and Learning Complex
Adult Shirt Size
Gender?	Male Female
Size?	XS S M L XL 2XL 3XL