| Form: |
Veteran Application |
|
Honor Flight recognizes American veterans for your sacrifices and achievements by flying you to Washington, DC to see YOUR memorial at no cost. Top
priority (for which we are currently accepting application only) is given to WW II and terminally ill veterans from all wars. In the future, Honor Flight will be
expanded to include Korean and Vietnam veterans. In order for Honor Flight to achieve this goal, guardians fly with the veterans on every flight providing
assistance and helping veterans have a safe, memorable and rewarding experience. For what you and your comrades have given to us, please consider this a
small token of appreciation from all of us at Honor Flight.
|
|
| Personal Information |
First Name
(As it appears on your
ID for airline travel) |
|
Last Name
(As it appears on your
ID for airline travel) |
|
| (if needed) Nickname |
|
| Address |
|
| (if needed) Address 2 |
|
| City,State,Zip |
, |
| Daytime Phone |
|
| Nightime Phone |
|
| Cell Phone |
|
| Email |
|
| T-Shirt size |
Weight
Age |
| How did you hear about us? |
|
|
Alternate Contact
(son, daughter, etc) |
Name
|
|
Relation
|
|
| Daytime Phone |
|
| Nightime Phone |
|
| Cell Phone |
|
| Email |
|
|
| Emergency Contact |
Name
|
|
Relation
|
|
| Address |
|
| (if needed) Address 2 |
|
| City,State,Zip |
, |
| Daytime Phone |
|
| Nightime Phone |
|
| Cell Phone |
|
| Email |
|
|
| Service History |
Branch of Service
|
|
Rank
|
|
Home Town
(from which city and state
did you enter the service?) |
|
| ACTIVITY DURING WWII |
|
|
| Medical Information |
|
Information provided will not disqualify you. It permits us to assess the support we need during the trip. Info is for honor flight and medical personnel only.
|
Do you use mobility equipment?
If YES, please check device:
|
cane
walker
wheelchair
scooter
|
Please List drug allergies:
|
|
Medications
(please indication type and how often) |
|
|
Do you have a history of seizure?
|
Type: |
When was your last seizure?
|
|
| If within past 5 years, strongly advised you discuss trip with your private
physician! |
|
Do you have problems with
motion sickness (sea or air)??
|
|
If yes, is it controlled with medications?
|
|
| If motion sickness is not controlled with medications, it is strongly advised you discuss the trip with your private physician! |
|
Do you have any breathing problems?
|
|
If YES, please describe:
|
|
Do you use a home nebulizer machine?
|
|
| If YES, you are strongly encouraged to discuss the trip with your private
physician concerning the use of portable hand-held nebulizers during the trip. |
|
Do you use oxygen at any time?
|
|
| If YES, you will need your private physician to write a prescription for oxygen to
be used during the flight and during the tour. Oxygen will be provided. The prescription should be faxed or emailed within a week of filling out this application. |
|
Do you have a problem walking
the length of a football field
without assistance?
|
|
If yes, please describe the reason
(e.g. lung problems, arthritis, heart problems, etc.)
|
|
|
Do you have a history of open
head injuries, sinus problems,
or ear problems?
|
|
If YES, have you flown since
the open head injury, sinus or
ear problems occurred?
|
|
If YES, it is strongly advised you discuss the trip with your private physician. If you have NEVER flown since the open
head injury, sinus or ear problems, again we strongly advise you discuss the trip with your private physician.
|
|
Do you have a urostomy or colostomy bag?
|
|
| If YES, please make sure the bag is vented prior to flight. If you do not
know if your bag is vented, it is strongly advised that you discuss this issue with your private physician. |
|
| Additional Comments or Concerns |
|
|
The undersigned acknowledges and agrees that:
1. As photographic and video equipment are frequently used to memorialize and document Honor Flight trips and
events, his/her image may appear in a public forum, such as the media or a website, to acknowledge, promote or
advance the work of the Honor Flight program. I hereby release the photographer and Honor Flight from all
claims and liability relating to said photographs. I hereby give permission for my images captured during Honor
Flight activities through video, photo, or other media, to be used solely for the purposes of Honor Flight
promotional material and publications, and waive any rights or compensation or ownership thereto.
2. I further state that medical insurance is the responsibility of the veteran and I understand that Honor Flight does
NOT provide medical care. I understand that I accept all risks associated with travel and other Honor Flight
activities and will not hold Honor Flight responsible for any injuries incurred by me while participating in the
Honor Flight program.
|
I agree to the above
|
(you may have to sign a release before the flight) |
Date
|
|
|
Flight Schedule