Military Autism Medical Waiver Request Form
Request a military medical waiver related to autism. Please provide accurate information to support your waiver request.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Branch of Military
*
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Other
Relationship to Service Member
*
Self
Parent/Guardian
Spouse
Other
Reason for Waiver Request
*
Brief Medical Summary (related to autism diagnosis and waiver need)
*
Supporting Documentation (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Waiver Request
Should be Empty: