Veteran Stand Down Registration

This registration is for Veterans only who would like to connect to services. If you are a provider please register here.

Veteran Name(Required)

First Middle Last

Is this your last name while in active duty?(Required)

Yes

Birth Date:(Required)

Please provide your active duty last name:(Required)

Phone

Social Security Number:

Do you need transportation to and from the Stand Down?

Yes

What city are you located in?

Are you working with an organization or social service provider?

Yes

Please provide the agency name:

Social Worker Name:

First Last

Phone

Release of information and Liability:

As a participant in the Veteran Stand Down event, I acknowledge that the following information will be collected as part of my registration:

Full name
Date of birth
Branch of military service
Phone number
Email address
Social Security Number

This information will be used by the County of Ventura and the U.S. Department of Veterans Affairs (VA) to verify my veteran status prior to the event and to assess my eligibility for VA healthcare and VA disability benefits.

I authorize the County of Ventura and the U.S. Department of Veterans Affairs to share the above information with designated partner agencies solely for the purpose of connecting me to appropriate services and resources during the Veteran Stand Down event. These partners may include local nonprofit organizations, government agencies, and service providers focused on housing, employment, healthcare, and other veteran support services.

This release applies only to my personal information and does not authorize the release of information regarding my dependents. SSN will only be shared with the VA and no other entity.

Participation in the event is not dependent on signing this release. If I choose not to authorize the sharing of my information, I understand that it may limit my access to certain services or referrals, but I am still welcome to participate.

Consent(Required)

I consent to the collection and sharing of my information as described below

I do not consent to the sharing of my information

Release of Liability(Required)

I hereby release and hold harmless the County of Ventura, its employees, or its officials from all actions, claims, or demands that I now have or may hereafter have for injury or damage resulting from my participating in the event. I am aware that this is a release of liability and an agreement between me and the County of Ventura and sign it of my own free will.

Phone

This field is for validation purposes and should be left unchanged.

Veteran Stand Down Registration

Veteran Stand Down Registration

Release of information and Liability:

Menu

Contact Information

Resources

Quick Links

Social Media