Personal Information

Name: *

Age: *

Address: *

Phone: *

E-mail address: *


Family Information

Marital Status: *

Spouse Name: *



Military Service

Military Status: *
Active DutyReserve DutyVeteranGuard Duty

Military Branch: *
ArmyAir ForceNavyMarine CorpCoast Guard

Current or EAS Rank: *

Military Job Description: *

Current or last military station:

Military Operations Involved In: *
OIFOEFDesert StormOtherNone

Military Service Photo (attachment required): *

DD-214 or LES or photo of military ID (photocopy attachment required): *


Support System Information

Primary Support Member Name (other than spouse): *

Primary Support Member's Phone Number:

Primary Support Member's E-mail address: *


Reason(s) for applying to participate in The Surrender Project *

Personal Goals (include both current and long term) *


Healthcare Information (if applicable)

Primary Physician Contact Information:

List any chronic physical injuries or impairments:

Psychologist/Therapist Contact Information:

List any current conditions or past diagnosis:

List all current medications:


Privacy/Release Statement

I, (insert name below)*

do hereby attest that the information provided is true and accurate to the best of my knowledge. I also understand that the submission of this nomination package in no way guarantees my acceptance into The Surrender Project. The Nomination Committee determines acceptance after a thorough review of each nomination package.

I, (insert name below)*

do hereby release the above information to be used by SOF Missions and The Surrender Project Nomination Committee for the purpose of determining eligibility for The Surrender Project. if accepted into the Surrender Project, hereby consent to the use of to Shield of Faith Missions Inc. and/or their agents, affiliates, or authorized representatives of photographs or videos in which I appear, and I acknowledge and agree that I have no ownership rights in or to those photographs or videos. I hereby release Shield of Faith Missions Inc. and/or their agents, affiliates, authorized representatives and assigns from any claims that I may have relating to any photographs or videos, including without limitation, any claim arising under the right of publicity, the right of privacy, defamation and/or copyright infringement. I am aware that SOF Missions will share my information with the other Surrender Project partnering organizations.

I, (insert name below)*

understand that SOF Missions is committed to helping service members, veterans, and their dependents. In order to achieve the optimum results, I will at all times be truthful with SOF Missions employees and volunteers. Should I disclose information indicating my intent to cause substantial bodily harm to myself or others, I understand that SOF Missions may be obligated by law to disclose some or all of that information in order to protect myself or others. I hereby agree to allow SOF Missions employees or volunteers to disclose information, upon reasonable belief that I will cause imminent and substantial bodily harm to myself or others, necessary to prevent such injury.

By checking this box I agree to the terms and conditions above.

Signature: *

Date: *