OPERATION HEAL OUR PATRIOTS
®
Operation Heal Our Patriots gives wounded veterans and their spouses the opportunity for spiritual refreshment, physical renewal, and marriage enrichment. Couples participate in Biblically-based seminars that help strengthen their relationships with God and others and enjoy the beauty of God’s creation with outdoor activities at our Alaskan wilderness lodge. We continue to support these men and women after their initial stay, keeping their spiritual needs and marriages a priority.
This form is best filled out using your desktop computer.
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We will start accepting applications in January 2019.
Wounded Soldier Information
Injury
Spouse
Describe Yourself
Are you a service member from a Canadian military branch who has been injured or wounded in active duty after September 11, 2001? If so, and you would like to reconnect with your spouse in a stress-free environment, you may be eligible for Operation Heal Our Patriots.
Your Information
First Name
Last Name
Middle Name
Preferred Name
Gender
Please Choose...
Male
Female
Branch of Service
Please Choose...
Royal Canadian Navy
Royal Canadian Navy Reserve
Royal Canadian Air Force
Royal Canadian Air Force Reserve
Canadian Army
Canadian Army Reserve
Highest Rank Held
Please Choose...
Able Seaman
Acting Sub Lieutenant
Admiral
Aviator
Aviator (Basic)
Bombardier
Brigadier General
Canadian Forces Chief Warrant Officer
Captain
Chief Petty Officer 1st Class
Chief Petty Officer 2nd Class
Chief Petty Officer of the Navy
Chief Warrant Officer
Colonel
Command Chief Warrant Officer
Commander
Commodore
Corporal
Craftsman
Formation Chief Petty Officer
Formation Chief Warrant Officer
Fusilier
General
Guardsman
Gunner
Leading Seaman
Lieutenant
Lieutenant Colonel
Lieutenant General
Lieutenant-Commander
Major
Major General
Master Bombardier
Master Corporal
Master Seaman
Master Warrant Officer
Naval Cadet
Officer Cadet
Ordinary Seaman
Petty Officer 1st Class
Petty Officer 2nd Class
Private
Private (Basic)
Rear Admiral
Rifleman
Sapper
Second Lieutenant
Sergeant
Signalman
Sub-Lieutenant
Trooper
Vice Admiral
Warrant Officer
Status
Please Choose...
Active
Reserve
Retired
Medically Retired
Military Service Start Date
Military Service End Date
Address Line 1
Address Line 2
City
Province
Please Choose...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Home Phone
Cell Phone
Email Address
Preferred Contact Method
Home Phone Number
Cell Phone Number
Email
Marital Status
Please Choose...
Married
Common Law
Other
Marriage Date
Date of Birth
Injury
Date of Injury
Please select the entries that best describes the nature of your injury
Amputee (arm)
Amputee (leg)
Burn Wound
Shrapnel or bullet wound
Vision loss
Hearing loss
PTSD
Debilitating Organ Injury
TBI - Traumatic Brain Injury
Paralyses
Chronic pain from broken bones and or torn muscles
OSI - Operational Stress Injury
Please provide a detailed description of your injury (or injuries), the cause of your injury, and related restrictions (e.g., balance issues, difficulty climbing stairs, etc.)
Primary Care Physician Info
Name
Address Line 1
City
Province
Please Choose...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavat
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Phone Number
Emergency Contact Info
Full Name
Relationship
Phone Number
Are you currently receiving medical treatment? If so, please describe, and include any special medical needs
Spouse
First Name
Last Name
Middle Name
Preferred Name
Gender
Please Choose...
Male
Female
Home Phone
Cell Phone
Email Address
Date of Birth
Military Service
Yes
No
Spouse Military Information
Branch of Service
Please Choose...
Royal Canadian Navy
Royal Canadian Navy Reserve
Royal Canadian Air Force
Royal Canadian Air Force Reserve
Canadian Army
Canadian Army Reserve
Highest Rank Held
Please Choose...
Able Seaman
Acting Sub Lieutenant
Admiral
Aviator
Aviator (Basic)
Bombardier
Brigadier General
Canadian Forces Chief Warrant Officer
Captain
Chief Petty Officer 1st Class
Chief Petty Officer 2nd Class
Chief Petty Officer of the Navy
Chief Warrant Officer
Colonel
Command Chief Warrant Officer
Commander
Commodore
Corporal
Craftsman
Formation Chief Petty Officer
Formation Chief Warrant Officer
Fusilier
General
Guardsman
Gunner
Leading Seaman
Lieutenant
Lieutenant Colonel
Lieutenant General
Lieutenant-Commander
Major
Major General
Master Bombardier
Master Corporal
Master Seaman
Master Warrant Officer
Naval Cadet
Officer Cadet
Ordinary Seaman
Petty Officer 1st Class
Petty Officer 2nd Class
Private
Private (Basic)
Rear Admiral
Rifleman
Sapper
Second Lieutenant
Sergeant
Signalman
Sub-Lieutenant
Trooper
Vice Admiral
Warrant Officer
Status
Please Choose...
Active
Reserve
Retired
Medically Retired
Military Service Start Date
Military Service End Date
Spouse Address Different from Applicant?
Yes
No
Spouse Address
Address Line 1
Address Line 2
City
Province
Please Choose...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavat
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Spouse Emergency Contact Different from Applicant?
Yes
No
Emergency Contact Info
Full Name
Relationship
Phone Number
Spouse Primary Care Physician Different from Applicant?
Yes
No
Primary Care Physician Info
Name
Address Line 1
City
Province
Please Choose...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Phone Number
Is your spouse currently receiving medical treatment or do they have any significant medical issues or physical restrictions?
Yes
No
If so, please describe, and include any special medical needs.
Describe Yourself
Please attach a photo of just you and your spouse together. No family photos please.
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Describe why you feel that you and your spouse would benefit from Operation Heal Our Patriots.
Please provide a detailed description of any dietary restrictions you or your spouse may have.
Please list any additional comments or special needs that will help us better prepare for your visit.
If you have been sponsored or recommended by a group or individual, please let us know who. Enter "N/A" if not applicable.
How did you learn about this program?
Describe your past relationship with church or religion. Enter N/A if not applicable.
By submitting this application you are agreeing to our
Legal
and our
Privacy Policies
. Samaritan's Purse – Canada (SPC) retains your personal information as confidential. The information you provide will be used to inform you of our programs and projects, to help encourage you spiritually, and to provide you opportunities to support our work. Please contact SPC at 1 800 663 6500 or email
info@samaritan.ca
if you do not want your information used for the purposes described. Please be aware that Samaritan’s Purse Canada carries out the Operation Heal Our Patriots program in collaboration with Samaritan’s Purse’s International Head Office in Boone, North Carolina, USA. Therefore, to effectively deliver this program your personal information will also be provided to Samaritan’s Purse in the United States of America where your personal information may be collected, used, processed, stored or disclosed in accordance with the Policies of Samaritan’s Purse in the United States and US legislation regarding personal information privacy.
For more information or if you have questions please call 1.800.663.6500.
I have read and agreed to the conditions above