Application

"Operation Black Hills Cabin" APPLICATION

Who is qualified to apply:
Active Duty service members and Veterans who served in any post-September 11, 2001 military operation and who are Combat Injured at a minimum of 30%. Such military operations include, but are not limited to: Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), Operation New Dawn (OND), Operation Odyssey Dawn (OOD), NATO's Operation Unified Protector (OUP), Operation Inherent Resolve (OIR), Operation Freedom's Sentinel (OFS), Operation Resolute Support (ORS), Operation Enduring Freedom - Trans Sahara (OEF-TS), or Operation Juniper Shield (OJS).

OR Soldier Recovery Unit members. Include a copy of orders with the assignment to SRU, AND a signed statement from the applicant's primary physician on the physician's letterhead with the physician's contact information, and stating the member is pending a Statement of Disability with an anticipated rating of at least 30% due to Combat Injuries along with the type of disability.

This form can be filled in and submitted online, OR printed (right click on form to print) and mailed to us with supporting documentation to the address at the bottom of the application. No action will be taken on any submitted application until all supporting documentation has been received.

* Indicates required field

Signature *

Please complete the following application in it's entirety.
Fully completed applications and supporting documentation will be reviewed on a first come, first served basis. Any lines left blank, or illegible, will lengthen the acceptance process, and may hinder your respite week. Please make sure all required documentation is included. CONFIDENTIALITY POLICY: All of your information is kept confidential. Operation Black Hills Cabin will not use, sell or disclose any information without your written consent.

Military member's name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alternate Phone Number *

Email *

Is military member Active Duty or Discharged *

Who is military member's OEF/OIF/OND Case Manager *

Which VA Health Care System is military member assigned to *

Branch of Service *

Military Member's Employer *

Occupation *

Spouse *

Spouse's Employer *

Spouse's Occupation *

Total number & names of people staying in the cabin (please include ages of children). This is an opportunity to reconnect with your immediate family as listed as dependents on your Award Letter, without the daily pressures of therapy, doctor appointments, etc. This is not the time to bring neighbors, friends, people not in your immediate family or individuals who are not caregivers, etc. *

Family Interests & Activities *

Please tell us about your family *

Please provide a brief history of your military career *

Please provide a brief detail of your combat related injuries *

Please provide 3 personal references not related to you below: (Name, Phone, Address & Email)

Personal Reference 1 *

Personal Reference 2 *

Personal Reference 3 *

May we have permission to contact your references? *

Yes No

Will anyone staying in the cabin be using a wheelchair? *

Yes No

Does the service member have a Registered Assistive Service Animal that will be accompanying him/her? *

Yes No

Where did you find out about us? *

Please list 3 dates of preference for the week you would like to stay in the cabin. A week is from Sunday at 3 pm (check in) to the following Saturday at 10 am (check out) *

Please list any dates you CANNOT accept for your reconnection respite week. *

Are you willing to accept dates during the months of May, August, September, or October? *

Yes No

If you are on a waiting list, and a week becomes available, what is the minimum amount of notice that would be acceptable to you to utilize an open week? *

I understand that if we have additional people or unauthorized pets staying in the cabin or on the premises, we will be asked to leave immediately and will forfeit the remainder of our stay in the cabin. (Please sign below if you accept) *

PLEASE NOTE: Transportation is the responsibility of each family. However, due to grants received and donations from many individuals and organizations, we are able to provide each family upon arrival transportation assistance in the form of a Visa card.

Send documentation to:
Operation Black Hills Cabin
PO Box 855
Custer, SD 57730

Include a copy of the service member's current DD Form 214 as well as the Award Letter. This is the letter from the VA showing the breakdown of injuries and total disability percentage as well as a list of dependents. Only individuals listed as dependents on the Award Letter, or official caregiver (accompanied with official VA documentation), will be allowed to accompany the combat-injured veteran. DO NOT send us your SSAN. We recommend that you make a copy of your original documents and block out or cut out your SSAN prior to sending or scanning the copy. DO NOT damage your originals.

PLEASE NOTE: No action will be taken on any application submitted until we have received the required documentation as listed above. You may mail to the PO Box listed above, or scan and email the required documentation to [email protected]. No photographs will be accepted. All applications together with their required documentation will be reviewed on a first come first serve basis. If all qualifications have been met, our next step will be contacting your references. With this process completed, we will then contact you to make further arrangements. All travel expenses are your responsibility, however, travel assistance is given upon arrival. Feel free to contact us should you have any questions.

Operation Black Hills Cabin is a South Dakota 501(c)3 non-profit organization founded by a retired military couple.
Custer and the State of South Dakota have taken a very active part in OBHC, and this project is a way for us to say "Thank You" for your service and sacrifice.

Submit