Director, Coaches

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Complete this form only if you are available for coaching for six months beginning in February 2010. This is confidential information and will be public only to the Project Director and your assigned Coach and Military Liaison.

This site is a not-for-profit public charity organization under IRS code 501(c)(3),
and is continually updated in order to better serve our veterans.



	Name* First Name Last Name
	Address* City State Zip Code
	Primary Phone Number* (xxx) xxx-xxxx
	Secondary Phone Number* (xxx) xxx-xxxx
	Email*
	Gender Male Female
	Ethnicity African American Asian Caucasian Hispanic Native American Other: Other Value
	Branch of Service Army Air Force Coast Guard Marine Corps Navy

	Rank / Rate:
	Period of Service: ___________ to ___________
	Theater of Service: Operation Iraqi Freedom Operation Enduring Freedom
	What is your VA ratable level of physical disability? ____%


	Please let us know more about you. Include any barriers you have faced in achieving your life goals since leaving military service.