Veteran Registration FormPersonal InformationName* First Last Phone*Birth Date* Date Format: MM slash DD slash YYYY Gender*MaleFemaleAge*Email County currently living in?Current Address or Shelter Location where you are staying Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you bringing a service animal?YesNoWhat kind of service animal?If you are planning to bring any family members to the Stand Down please provide their name and date of birth.Branch of Service* Air Force Army Coast Guard Marines Navy National GuardYears Served YYYY-YYYY*Where are you currently living?*Living in own home/aptLiving in HUD VASH housingLiving with family or friendsLiving in transitional housing/shelterHomeless- living in a car or on the streetsOtherAre you in a Wheelchair or have limited mobility?*YesNoWill you need special accommodations while attending the Stand Down?*YesNoIf Yes, please explain.TransportationIf you are providing your own transportation to the Stand Down, do you plan on staying overnight?YesNoWill you need transportation to the Stand Down?*YesNoAll pick-ups will be on Friday AM, October 18th. You must stay both Friday night and Saturday night. We will provide transportation back on Sunday AM to same location as pick up. Please select from a stop below.Alpha Bus #1 - Pinellas CountyPlease SelectStop 1: 08:00-08:05 @ Center of Hope (401 15th St. N. St. Petersburg, 33705)Stop 2: 08:30-08:35 @ Bay Pines VA (10000 Bay Pines Blvd, St. Petersburg, 33708 "PTSA Bus Area #62 off 100th Way")Stop 3: 08:50-08:55 @ Boley Morningside Safe Haven (9220 102nd Ave. N. Seminole, 33777)Alpha Bus #2 - Pinellas/Pasco CountyPlease SelectStop 1: 08:00-08:05 @ Pinellas Safe Harbor (14840 49th St N. ClearwaterStop 2: 08:15-08:20 @ Pinellas Hope (5726 126 Ave, Clearwater, 33760)Stop 3: 08:45-08:50 @ HEP (1120 N. Betty Ln., Clearwater, 33755)Stop 4: 09:20-09:25 @ St. Timothy Lutheran Church (812 E. Tarpon Ave., Tarpon Springs)Stop 5: 09:35-09:40 @ Metropolitan Ministries (3214 US Hwy. 19, Holiday, 34690)Stop 6: 10:00-10:05 @ VA Clinic Center (9912 Little Rd., New Port Richey)Bravo Bus #1 - West Pasco CountyPlease SelectStop 1: 08:00-08:05 @ Career Source, 4440 Grand Blvd, New Port RicheyStop 2: 08:15-08:20 @ Pasco County Vet Center, 5139 Deer Park Drive, New Port RicheyStop 3: 08:35-08:40 @ Gulf View Square Mall, 9409 US Hwy. 19, Port RicheyStop 4: 08:45-08:50 @ Smile Faith Vet Clinic, 8125 US 19, Port RicheyStop 5: 09:00-09:05 @ Acts Resource Center, 12515 US Hwy. 19, HudsonCharlie Bus #1 - East Pasco CountyPlease SelectStop 1: 08:00-08:05 @ Flying J, 29933 SR. 52, San Antonio, 33576Stop 2: 08:20-08:25 @ Career Source, 15000 Citrus County Dr, Dade CityStop 3: 08:35-08:40 @ Vet Service Center, 13920 17th St & Florida Ave, Dade CityDelta Bus #1 - Hernando CountyPlease SelectStop 1: 09:00-09:05 Career Source, 7361 Forest Oaks Blvd, Spring HillStop 2: 09:20-09:25 @ Brooksville Vets Clinic, 14541 Cortez Blvd, BrooksvilleStop 3: 09:35-09:40 @ Veterans Services, 621 W. Jefferson St, BrooksvilleEcho Bus #1- HillsboroughPlease SelectStop 1: 08:50-08:55 @ Hart University Area Transit Center, 131 Ave and N. 27th St. TampaStop 2: 09:05-09:10 @ VA Eye Clinic, 10770 N 46th St. Bldg, F, TampaVeterans Court - Pasco County Offenses OnlyPlease fill out the information below if you want a case heard: PASCO VETERANS COURT ONLYFL License NumberPasco County Court Case Number (if applicable)Court Cost Due?YesNoWhat are the charges? (if known)
