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Armed Forces Retirement Home
Request Form

Thank you for your interest. To help us provide you with the most appropriate information, please complete and submit the following form
~ OR ~
Go to Contact Us for specific campus phone numbers.

For yourself or the person for who you are inquiring to live at AFRH
* = Required Information

Are you looking for senior living options for:

* What best describes the current living situation:
Live in own home independently (not using home care services)
Live in own home and receiving home health care services
Live in community for independent seniors
Live in an assisted living community
Live in a long term care facility

What is the date of birth (MM/DD/YYYY)?

What best describes the military status:(Check all that apply)
Veteran with 20 or more years of active-duty who is at least 60 years old
Veteran who is unable to earn a livelihood due to a service-connected disability
Veteran who is unable to earn a livelihood due to a nonservice-connected disability and who served in a war theater or received hostile fire pay
Female veterans who served prior to 1948

What best describes the previous military branch of service:(Check all that apply)
Air Force
Army
Coast Guard
Marines
Navy

* How soon do you think you will need senior living services?
Immediately
Within 3 months
Within 6 months
Within year
Not sure - just gathering information

* Please select the campus you are interested in:
Washington
Gulfport
Both

How did you hear about AFRH?


Contact Information

Would you like to:
receive contact from one of our representatives
receive an information packet by mail

Please enter any comments or questions you have about AFRH or its campuses:

* First Name:

* Last Name:

* Street Address:

* City:   * State:   * Zip Code:

* Country:

Phone Number:

E-mail Address:

Best time to call:

                             

PRIVACY ACT STATEMENT
5 U.S.C. § 552a

If you complete a form or send a letter or e-mail, you may be choosing to send us information which personally identifies you. This information is used generally to respond to your request but may have other uses which are identified on each form.

If you have questions about AFRH's privacy policy and information practices you can e-mail the webmaster.

Last Updated July 30, 2008