Request Veteran Support | Vann Rainey Veterans Alliance

Thank you for contacting Vann Rainey Veterans Alliance. This form helps us understand your interests and determine whether the Veterans Community Support & Wellness Pilot Program may be appropriate for you. Submitting this form does not guarantee enrollment, transportation, financial assistance, or any particular service. A member of our team will review your request and contact you.

1. Contact Information

Legal first name *

Legal middle name (optional)

Legal last name *

Preferred name (optional)

Date of birth *

Street address *

Apt / unit (optional)

City

State

ZIP code

County

Primary telephone number *

Alternate telephone number (optional)

Email address (optional)

Required only if you do not provide a telephone number.

Preferred contact method

Best days and times to contact you

Permission to leave a voicemail Permission to send a text message

2. Veteran Information

Are you a veteran of the United States Armed Forces?

Yes No Unsure

Branch of service

Other branch or service component (optional)

Beginning year of military service (optional)

Ending year of military service (optional)

Discharge status (optional)

Are you currently connected to VA services?

Yes No Unsure

Do you need help locating military-service documentation?

Yes No

We do not request a Social Security number, VA claim number, military ID number, medical record, or a copy of your DD-214 through this form.

3. Residency and Pilot Eligibility

Do you currently reside in Hillsborough County?

Yes No

Community or neighborhood

ZIP code

Are you 18 years of age or older?

Yes No

Are you interested in participating in a 90-day pilot program?

Yes No

Are you willing to participate in program follow-up and a satisfaction survey?

Yes No Unsure

The pilot's primary service area is East and South Hillsborough County. Applications outside the primary service area are flagged for staff review and are not automatically rejected.

5. Accessibility and Communication

Preferred language

Preferred way to receive program information

Interpreter requested?

Communication assistance requested?

Mobility or accessibility accommodation requested?

Brief accommodation description (optional)

6. Referral Information

How did you hear about Vann Rainey Veterans Alliance?

Referring organization name (optional)

Only if you choose to provide it.

Referral contact information (optional)

7. Emergency and Immediate Assistance Notice

Important:

Vann Rainey Veterans Alliance does not provide emergency medical care, crisis intervention, or emergency housing through this form. If you are in immediate danger, call 911. Veterans experiencing a mental-health crisis may call 988 and press 1, text 838255, or contact the Veterans Crisis Line.

Is your request related to an immediate safety emergency?

Yes No

8. Applicant Acknowledgment

The information provided is accurate to the best of my knowledge. Submitting this form does not guarantee enrollment or services. I give Vann Rainey Veterans Alliance permission to contact me about this request. I understand a separate consent and information-release form may be required before information is shared with another organization.

Applicant's typed name *

Submission date

I understand this electronic acknowledgment serves as my signature. This form was completed by someone other than the veteran.

This acknowledgment is not the full program consent or information-release authorization.

Your information is protected and will only be reviewed by authorized program staff.

Veteran Intake and Eligibility Form