Veteran Homeless Shelter Intake Form
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Prefer not to say
Phone Number
Email Address
Last Permanent Address
Branch of Service
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Other
Service Dates
Discharge Status
Honorable
General
Other than Honorable
Bad Conduct
Dishonorable
Emergency Contact Name
Emergency Contact Phone
Medical Conditions
Current Medications
Immediate Needs
Additional Comments