Prince George's County Department of Parks and Recreation
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Personal Interest Form

Healthy_Minds

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:
Date of Birth:  calendar
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Street  Address:
City, State, Zip

    
County:
Telephone:
Email Address:
   
Did you receive a discharge under honorable conditions?  
Can you provide verification of honorable discharge and 10% or more disability?  

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?
Description of Primary Disability:
How did you hear about this program?
Which facility would you like to host your membership?