General Information

First Name

Last Name

Email

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Zip/Postal Code

Branch of Service

Please provide your rank

Please describe your current status:

Please describe the wounds, illness or injury sustained and how long you expect to be receiving care at the hospital.

Marital Status

Do you have children?

Please provide the names and ages of each child:

Do you have a Caregiver?

Please provide your Caregivers name as well as your relationship (Ex: Mary - wife).

Who were you referred by:

What services are you in need of?

Select from the options below to determine your specific request:

Housing

**PLEASE ONLY FILL THIS SECTION OUT IF YOU ARE REQUESTING SHORT TERM HOUSING**

The Yellow Ribbon Fund provides hotels to service members with families who are receiving care or treatment at Walter Reed. Please answer the following questions and provide the documentation listed below for consideration for the short term housing.

Hotel stays will be awarded for a maximum of 14 days. YRF must be notified at least 7 days in advance for extension requests and cannot guarantee the request until documentation for extension is provided.

Required Documentation :

FOR RETIRED/VETERAN STATUS

*Letter of endorsement from Command
*Proof of VA initiation and/or letter from case manager
*Copy of ID (anyone in the household 18 or over)
*Most recent VA compensation paperwork

FOR ACTIVE DUTY

*Letter of endorsement from Command
*Proof of VA initiation and/or letter from case manager
*Copy of ID (anyone in the household 18 or over)
*Supporting documents
*Proof of mortgage or lease

Where are you receiving care?

Describe reasons for your visit

Do you need an ADA compliant room?

Please provide the length of time you will need a hotel room (# of total nights)

Arrival Date

Transportation

The Yellow Ribbon Fund provides car rentals to families/caregivers of service members who are receiving care or treatment at Walter Reed. Please answer the following questions and provide the documentation listed below for consideration for the short term housing.

*CAR RENTALS CANNOT BE RENTED TO THE SERVICE MEMBERS RECEIVING CARE/TREATMENT AT THE FACILITIES DUE TO LIABILITY CONCERNS. ALL RENTALS WILL BE WITH THE CAREGIVER OR FAMILY MEMBER.

Car rentals will be awarded for a maximum of 30 days. YRF must be notified at least 7 days in advance for extension requests and cannot guarantee the request until documentation for extension is provided.

Required Documentation:

FOR RETIRED/VETERAN STATUS

*DD214 (long copy)
*Copy of ID (anyone in household 18 or over)
*Proof of VA claim (or pending claim)
*Most recent VA compensation paperwork

FOR ACTIVE DUTY

*Letter of endorsement from Command
*Proof of VA initiation and/or letter from case manager
*Copy of ID (anyone in household 18 or over)
*Supporting documents
*Proof of mortgage or lease

Full Name of Driver (Last, First)

Relationship to service member

Drivers Contact Number

Drivers Email Address

Driver will provide valid license

Driver has FULL COVERAGE COMPREHENSIVE AND COLLISION INSURANCE for USA with a deductible of $500 or less

Does the service member have a wheelchair?

Reason for visit

Provide requested pick up date

Provide drop off date (please note, rental cars are given for a maximum of 30 days)

Total number of passengers in vehicle including the driver