Assistant Application

VetsRoll Assistant Application

(For Consideration as a VetsRoll Assistant)

Download Application

VetsRoll, Inc®
2026 Assistant
Application

➢ Assistant applications due by 6p, February 1, 2026
➢ Medical team applications due by 6pm, January 1, 2026
➢ First time assistants must be age 18-68 as of May 1, 2026

Sunday, May 17th - Wednesday, May 20th, 2026

Please send your completed application to:

Mail:

VetsRoll, Inc®
1777 Gardner St
South Beloit, IL 61080

Phone: 815-389-9630 (M-Sa)
Fax: 815-389-9631
E-mail: applications@vetsroll.org

PLEASE NOTE: To be considered for the May 2025 trip, this form MUST be submitted, in entirety, NO later than Feb 1st, 2025!!

IMPORTANT NOTE: VetsRoll 2025 selections require a signed COVID Acknowledgement and Assumption of Risk Release

If selected, you must be present on registration day, Saturday, May 17th, 2025!

Please make sure you do not have popups disabled in your browser before you submit the form. It will prevent you from being directed to the successful submission page.

Thank you for taking time to apply for the upcoming VetsRoll Trip. We will review your application and be in touch shortly.

There was an error submitting this form

Check here for consideration of Medical Team selection (Medical Team applications due by 6p, January 1, 2025)

Your full name as it appears on your driver’s license or state ID:

First:

Middle:

Last:

Nickname:

Date of Birth:

Gender:

Address:

City:

State:

Zip:

Home Phone Number:

Cell Phone Number:

Email:

Shirt Size, (for stocking purposes, must be purchased separately):

Emergency Contact

In event of an emergency (medical or otherwise), we require emergency contact for each participant.

Name:

Relationship:

Address:

City:

State:

Zip:

Home Phone:

Cell:

Email (Required):

Signed Agreements Information and Resource Pages

All forms must be agreed to for consideration of participation of VetsRoll trip.
By checking the boxes, you are agreeing to terms and conditions and providing an electronic signature of applicant name on this form.

Covenent Not to Sue and Agreement to Hold Harmless Terms and Conditions

Covid Acknowledgement and Assumption of Risk Release

Assistant Expections

Signed Agreements:

Covenant Not to Sue and Agreement to Hold Harmless

Covid Acknowledgement and Assumption of Risk Release

Assistant Expectations

VetsRoll, Inc® Medical Information

Name:

Date of Birth:

Address:

City:

State:

Zip:

Gender:

Male Female

Home Phone:

Cell:

Physician's Name:

Facility:

City:

State:

Phone Number:

After Hours Phone Number:

Medical History

(Please check all that apply)

Asthma

CHF

Diabetes

Hepatitis

Phychological

Smoker

Bronchitis

COPD

Dialysis*

HIV/AIDS

Pulmonary Edema

Stroke/CVA/TIA

Cancer

Dementia

Emphysema

Hypertension

Renal failure

Cardiac disease

Depression

Gastrointestinal

Liver failure

Seizures**

Thyroid

COVID-19 Vaccinated/Booster(s)

Do you wish to disclose Covid info?

Yes No Do not wish to disclose

Current Medications:

*Are you on Dialysis for kidney problems?:

Yes No

If yes, describe type and frequency:

**If you have a history of seizures, please describe (i.e. grand mal; petit mal; focal, etc.):

PLEASE NOTE: If you have experienced seizure activity within the past five years, we urge you to discuss this trip with your physician.

Food and Drug Allergies:

Do you have a friend who is an eligible Veteran, 'Rosie', or Assistant?

If you know an eligible Veteran, 'Rosie' or Assistant that you would like to travel with, please write their name and number belowand we will try, but cannot guarantee, to pair you together. Be sure they complete the appropriate application as well!

Remember, spouses are not eligile for the trip, unless they are also an eligible Veteran or 'Rosie-the-Riveter'

Friend's Name:

Phone:

Are they a Veteran or Assistant?

Veteran Assistant

Friend's Name:

Phone:

Are they a Veteran or Assistant?

Veteran Assistant

Friend's Name:

Phone:

Are they a Veteran or Assistant?

Veteran Assistant

Only in special circumstances will assistants and Veterans be able to room together. If you need to room with a Veteran or Assistant, please explain the circumstances.:

Medical Team Applicants Only

What is your medical provider status?

Active Inactive Volunteer Career

What is your medical background/certification?

EMT-B

EMT-I

EMT-P

CNA

LPN

Other

If Other, please define here:

Is your medical training level current?

Yes No

If you are not selected to be part of the medical team, are you willing to go as an assistant?

Yes No

Tell Us About Yourself

Sell yourself. Why will you make a great assistant?

Are you a Veteran? (NOT a requirement):

Yes No

What is your medical background/certification?

Active Retired Reserve Other

If Other, please define here:

Years Served in the military?

Honorably Discharged?

Yes No

Attained Rank:

Branch of Service:

Occupation:

Are you CPR certified?

Yes No

Do you Smoke?

Yes No

Any physical limitations that may restrict your ability to lift a person from a sitting to a standing position?

Yes No

If yes, please explain:

Are you strong enough to withstand the rigors of heavy luggage, assisting people on steps, etc?

Yes No

Do you have physical limitations that you feel restrict your ability to push a 225 lb person in a wheelchair?

Yes No

If yes, please explain:

Have you ever worked with seniors and their special needs before?

Yes No

If yes, please explain:

Please describe your involvement with VetsRoll.org and why you would make a great addition to the VetsRoll.org team in 3000 characters or less:

Go Back Continue...