Honor Flight

VETERAN APPLICATION: STEP 1 OF 3

Please review the following information for accuracy before submitting.

Personal Information

Name

Gender

Date of Birth

Shirt Size

ID Type

ID Number

Issuing State

Address

Phone (Best Reachable)

Alternate Phone

Service Information

I have served in the following war(s)

I have served in the following branch(es)

Contact Information

Guardian Request

Alternate Contact

()

Emergency Contact

()

I would like to be paired with

N/A

Medical Information

Do you use mobility equipment?

Do you have a Pacemaker?

Do you have a Defibrillator?

Are you a Diabetic?

Do you have drug allergies?

Have you ever had a seizure?

Please indicate all the medications you are taking and the frequency of each medication

None

Do you have problems with motion sickness?

Do you have breathing problems? (i.e. Asthma, COPD, shortness of breath, etc)

Can you walk the length of a football field without assistance?

Do you use a home nebulizer machine?

Do you use Oxygen?

Do you have a history of any of the following?

Have you ever experienced issues during flight related to head injuries, sinus problems or ear problems?

Do you have a urostomy or colostomy bag?

Do you have any serious medical concerns that we would need to know about?

General Information

How did you hear about Honor Flight?

Any Additional comments or concerns

Please review carefully and sign

I, the undersigned, acknowledge, and agree that:

I, the undersigned, acknowledge, and agree that: As photographic and video equipment are frequently used to memorialize and document Honor Flight trips and events, my 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 image, captured during any Honor Flight activities through video, photo, or other media, to be used for purposes of Honor Flight promotional material and publications, and waive any rights to compensation or ownership thereto.

I am solely responsible for obtaining medical insurance and I understand that Honor Flight does NOT provide medical care. I have discussed the information reflected in this application and my medical limitations with my doctor, and I accept all risks associated with travel and all other Honor Flight activities. I further agree, without limitation, on behalf of myself and any of my heirs, successors or assigns, to indemnify, defend and hold Honor Flight (including, without limitation, any officers, directors, employees, members, participants, users, volunteers or agents) wholly harmless for any injuries or any losses incurred by me while participating in any Honor Flight program.

Please sign here

Typing your name in the box below will serve as your signature.