Sacred Mountain Retreat Center Application Step 1 of 714%About YourselfName(Required)As it appears on your Government ID Card. First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number(Required)10 Digit Phone Number Including Area CodeEmail(Required) Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex(Required) Male FemaleRetreat Date(Required)April 4th - 11thApril 18th - 25thMay 9th - 16thMarital Status(Required) Single Married In a Relationship Divorced WidowedEmployment Status(Required) Employed Unemployed RetiredAbout Your ServiceBranch of Service(Required)Rank(Required) OIF OEF OtherDate You Entered Military/First Responder(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date You Left Military/First Responder(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Honorable or Dishonorable Discharge?(Required) Honorable DishonorableIf it was Dishonorable, why?Were you wounded during or after your service?(Required) Yes NoHow were you wounded?Please choose all experiences that apply:(Required) Combat Victim of Crime Domestic Violence Relationship Stress TBI Natural Disaster Serious Illness or Death of Loved One Child Abuse Sexual Assault PTSD Legal Problems Financial Stress Workplace Harassment Serious or Life-Threatening Illness Anger Outbursts OtherIf 'other' please explain.About Your HistoryWe need to know this information should there be a medical emergency while you are attending a retreat.Do you currently take any prescriptions for mental health care?(Required) Yes NoIf 'yes' what are you taking?Are you currently in or have you ever been in a treatment for alcohol, addiction, or substance abuse?(Required) Yes NoIf 'yes' please explain:Are you actively in treatment/therapy?(Required) Yes NoIf 'yes' please explain:Have you had a suicidal ideation or an attempt in the last 6 months?(Required) Yes NoHave you been charged with a violent crime?(Required) Yes NoIf 'yes' please explain:Have you been charged with a felony?(Required) Yes NoIf 'yes' please explain:Have you been charged with a DUI?(Required) Yes NoIf 'yes' how many?Do you have any food alergies?(Required) Yes NoIf 'yes' please list:About Your AccommodationsDo you have a service animal?(Required) Yes NoIf you are accepted to attend a retreat, will you be bringing your service animal?(Required) Yes NoHas your service animal been professionally trained?(Required) Yes NoName, breed and service provided?Does your service animal get along with other dogs?(Required) Yes NoDoes your service animal get along with other humans?(Required) Yes NoIf you bring your service animal, do you agree to: grooming prior to attending? Providing service documentation and veterinary records? Cleaning up after your dog?(Required) Yes NoDo you have any sleeping issues? C-pap machine, insomnia/symptoms?, night terrors/symptoms?(Required)Retreat CenterPlease tell us your personal goals for attending Sacred Mountain Retreat Center. What do you hope to achieve or change as a part of your work in this program?(Required)Please describe why you think this program will benefit you at this point in your life.(Required)Have you participated in any other veteran/first responder programs?(Required) Yes NoIf 'yes' which ones?Participants must commit to being a part of all events, group sessions and meals. We ask you to be on time and respect yourself and others.(Required) I Agree I Do Not AgreeDo you travel (plane or drive) with a firearm or knife?(Required) Yes NoIf yes, do you agree to turn it into SMRC?(Required) Yes NoCell phones, laptops and tablets will be left in your room during all activities. Cell service and Wi-Fi is restricted for the first 3-4 days.(Required) I Agree I Do Not AgreeHow did you hear about us?(Required) Family/Friend Social Media Google Website OtherSection BreakEmergency Contact Name(Required)Due to limited service, please give your emergency contact the SMRC landline 605.584.5040 First Last Emergency Contact Phone(Required)DocumentationPlease include the following documents along with your application:DD214 if you are a military applicant or Reference Letter for all other applicants.(Required)Please scratch out any sensitive number information such as Social Security Number and Driver’s License Number. Sacred Mountain Retreat Center is not held liable for any of this information if you fail to do so.Max. file size: 64 MB.Please Include a Photo of Yourself(Required)This is to ensure you are not a scammer.Max. file size: 64 MB.Your Story(Required)We need in your words, your story of your service time, trauma, and some sort of verbiage about YOU! Tell us about yourself!Has all sensitive information been scratched out from the documents uploaded above?(Required)By saying “yes” you agree that you are not sending us any sensitive numbers such as social security number or driver’s license number. You are also agreeing that Sacred Mountain Retreat Center is not liable for holding this information if you provide it to us. Yes NoSignature(Required)Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
