Online Registration for Families of the Homefront America Adopted Units

(Please note that all information will be verified by the sponsor's CO prior to distribution of goods.)

Select Unit Affiliation from List VMFAT 101 Squadron - San Diego California National Guard COMSUBRON 11 - ARCO (ARDM 5) COMSUBRON 11 - Deep submergence Unit COMSUBRON 11 - Naval Base Point Loma COMSUBRON 11 - Performance Monitoring Team COMSUBRON 11 - Sublearncen Det. COMSUBRON 11 - USS Asheville (SSN 758) COMSUBRON 11 - USS Hampton (SSN 767) COMSUBRON 11 - USS Helena (SSN 725) COMSUBRON 11 - USS Jefferson City (SSN 759) COMSUBRON 11 - USS Topeka (SSN 754)

PART I: APPLICANT INFORMATION

Last Name,    First Name,    MI     (If you are the spouse applying, please list your name as the applicant)                        

Home Address

 ................   

City, State, Zip code

......     .......     ...

Home Phone.......             Work Phone........              Cell Phone

E-Mail Address

PART II: SERVICE MEMBER INFORMATION

 ....................

Last Name,   First Name,     MI

Air Force Army Coast Guard Marines Navy National Guard      Currently Deployed?.. Yes No     

..................

Current Rank......................                     Pay Grade......         Yrs of Svc

..........   

Members Command...............................                           E-Mail Address

........................... 

Name of Command C.O.........................                          C.O.'s Work Phone......       C.O.'s Cell Phone

PART III: DEPENDENT CHILDREN INFORMATION

Childs First Name & Middle Initial          Grade Level  (Please use the child's grade for this coming fall)

 ........

........

........

........

........

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PART IV: NATIONAL GUARD FAMILIES ONLY

Will you be able to pick up your backpack(s) and supplies from your FAN Contractor, FRG, KVC, Command, or Program Coordinator?... Yes No

If Yes, please select your pick up location from the list.    Select from list - if applicable Camp Pendleton, Oceanside Camp SLO Fresno Los Alamitos Joint Forces Training Base Miramar MCAS, San Diego Point Loma Submarine Base, San Diego Sacramento San Juan Capistrano

If available, please provide the following information so we may notify the individual of your registration:

Name of FAN Contractor, FRG, KVC, Command, or Program Coordinator 

Phone number of above individual 

E-Mail address of above individual 

PART V: APPLICANTS CERTIFICATION

I Understand That:

• all information will be used solely for the purpose of determining my eligibility for assistance

• all information may be subject to verification in determining my eligibility for assistance

• all information must be submitted on 8 1/2” x 11” sheets

• my information will not be shared or sold to a third party without my written consent

• should Homefront America elect to use my and/or my family member’s testimonials, photo images of me and/or my family members, I/we will not be compensated for their usage

• my information may be retained by Homefront America for future program notifications

• should this grant be approved based upon inaccurate information, statements, omissions, or other misrepresentation that I have knowingly provided, I will be required to repay Homefront America in full for all benefits made to me

 I certify that:

• the information provided on this application is true to the best of my knowledge

• if request is granted, the goods and/or services received will be not be transferred or sold to a third party

• I will fully release, discharge, and hold harmless Homefront America, Inc and each of their affiliates, including but, not limited to their sponsors, volunteers, officers, and directors (collectively, “Releasees”) from any and all claims and liability that may arise as a result of my accepting the requested assistance

 I affirm that I have read and agree to the aforementioned terms and conditions... I Agree I Don't Agree