Application Form - Sacred Mountain Retreat Center

Sacred Mountain Retreat Center Application

Step 1 of 7

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About Yourself

Name(Required)

As it appears on your Government ID Card.

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

10 Digit Phone Number Including Area Code

Email(Required)

Date of Birth(Required)

Month

Day

Year

Sex(Required)

Male

Female

Retreat Date(Required)

Marital Status(Required)

Single

Married

In a Relationship

Divorced

Widowed

Employment Status(Required)

Employed

Unemployed

Retired

About Your Service

Branch of Service(Required)

Rank(Required)

OIF

OEF

Other

Date You Entered Military/First Responder(Required)

Month

Day

Year

Date You Left Military/First Responder(Required)

Month

Day

Year

Honorable or Dishonorable Discharge?(Required)

Honorable

Dishonorable

If it was Dishonorable, why?

Were you wounded during or after your service?(Required)

Yes

How 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

Other

If 'other' please explain.

About Your History

We 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

If '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

If 'yes' please explain:

Are you actively in treatment/therapy?(Required)

Yes

If 'yes' please explain:

Have you had a suicidal ideation or an attempt in the last 6 months?(Required)

Yes

Have you been charged with a violent crime?(Required)

Yes

If 'yes' please explain:

Have you been charged with a felony?(Required)

Yes

If 'yes' please explain:

Have you been charged with a DUI?(Required)

Yes

If 'yes' how many?

Do you have any food alergies?(Required)

Yes

If 'yes' please list:

About Your Accommodations

Do you have a service animal?(Required)

Yes

If you are accepted to attend a retreat, will you be bringing your service animal?(Required)

Yes

Has your service animal been professionally trained?(Required)

Yes

Name, breed and service provided?

Does your service animal get along with other dogs?(Required)

Yes

Does your service animal get along with other humans?(Required)

Yes

If 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

Do you have any sleeping issues? C-pap machine, insomnia/symptoms?, night terrors/symptoms?(Required)

Retreat Center

Please 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

If '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 Agree

Do you travel (plane or drive) with a firearm or knife?(Required)

Yes

If yes, do you agree to turn it into SMRC?(Required)

Yes

Cell 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 Agree

How did you hear about us?(Required)

Family/Friend

Social Media

Google

Website

Other

Section Break

Emergency Contact Name(Required)

Due to limited service, please give your emergency contact the SMRC landline 605.584.5040

First Last

Emergency Contact Phone(Required)

Documentation

Please 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

Signature(Required)

Date(Required)

Month

Day

Year