Dreams On Horseback · Military Connections Date Night

Please select which session you are registering for: *

This event is held from 7-8:30pm

Participant Information

Participant's Name *

First Name

Last Name

Email *

Verify Email *

Phone Number *

Participant's Date of Birth: *

(mm/dd/yyyy)

This participant is: *

Service member or veteran

Family of service member or veteran

Military Participant Demographics:

To help us to continue free programming for Military members and their families, we ask that you answer the following questions. The information provided is strictly for funding purposes and will not be shared or used to determine eligibility. THIS INFORMATION IS VOLUNTARY.

Branch of Service

Airforce

Army

Coastguard

Marines

National Guard

Navy

Select One:

Active

Honorably Discharged

Reserve

Rank?

Unit?

VA Disability Rating

Yes

No

Wounded Warrior?

Yes

No

Race:

White

Black or African American

American Indian and Alaska Native

Native Hawaiian and Other Pacific Islander

Ethnicity:

Hispanic

Non Hispanic

Are you bringing a guest?

Yes

No

Please provide the name of your guest. Your guest must sign the required Liability Forms in order to attend.