2. If you are interested in learning more about the Healthy Minds Healthy Bodies Program 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 --FemaleMaleOther
9. Other:
11. Date of Birth*
    Date of Birth
13. Phone Number*
14. Email Address*
16. Street Address*
18. City*
19. State*
20. Zip*
22. County*
24. Do you have a Parks Direct account?*

    1. Yes
    2. No
    3. I don't know
26. If yes, what is your Parks Direct account number?
28. Did you receive a discharge under honorable conditions? *

    1. Yes
    2. No
30. 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.
32. Dates of Service*
    Dates of Service Start Date

    —

    Dates of Service End Date
33. Branch of the military in which you served*
35. Were you injured during active duty? *

    1. Yes
    2. No
37. Description of Primary Disability*
39. How did you hear about this program?*
41. 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
43. Adult Shirt Size
45. Gender*
    -- Select One --FemaleMale
46. Size*
    -- Select One --Extra SmallSmallMediumLargeExtra LargeDouble Extra LargeTriple Extra Large
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field