Veterans Application Form Veteran FormFor Honor Flight Use OnlyL N: D R: Veteran ApplicationHonor Flight recognizes American veterans for your sacrifices and achievements by flying you to Washington, DC to see your memorial at no cost. Toppriority is given to WWII and terminally ill veterans from all wars. We are accepting applications from WWII, Korean, and Vietnam veteransas well as those terminally ill veterans from all wars. In order for Honor Flight to achieve this goal, guardians fly with the veterans on every flight providingassistance and helping veterans have a safe, memorable and rewarding experience. For what you and your comrades have given to us, please consider this asmall token of appreciation from all of us at Honor Flight. For further information, please contact us at (509) 624-0222 or visit us at www.inwhonorflight.orgYour Name Nickname AddressAddress City Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweState Zip Phone Day Phone Evening Mobile Email Address Age Weight Date of Birth How did you hear about honor flight? Tee shirt size - Select -SMLXLXXLXXXLPreferred Departing Airport Alternate Contact(son, daughter, etc.)Name Email Address Phone Relationship Emergency Contact Information(Someone available the day you travel)Name Address Mobile Relationship Phone Day Phone Evening Service HistoryBranch of Service Home Town (from which city and state did you enter the service?) Which war/conflict did you serve in? What were your years of Service? Rank What were your duties and where did you serve? MEDICAL: 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? Yes NoIf YES, please check applicable: Cane Walker Wheelchair Scooter Medication Taken How Often Do you use mobility equipment? Yes NoDo you have a history of seizure? Yes NoPlease describe what type (i.e. grand mal, petit mal, other) When was your last seizure? Do you have problems with motion sickness (sea or air)? Yes NoIf yes, is it controlled with medications? Yes NoIf 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? Yes NoIf YES, please describe Do you use a home nebulizer machine? Yes NoIf 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? Yes NoIf 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 turned in with the application.Do you have a problem walking the length of a football field without assistance? Yes NoIf 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? Yes NoIf YES, have you flown since the open head injury, sinus or ear problems occurred? Yes NoIf YES, did you have any problems? Yes NoIf 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? Yes NoIf 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: Please review carefully and signThe undersigned acknowledges and agrees that: 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. I further state that medical insurance is the responsibility of the veteran and I understand that neither Honor Flight nor the provider of free private aircraft ("Flight Provider") provides medical care. I understand that I accept all risks associated with travel and other Honor Flight Network activities and will not hold Honor Flight, the Flight Provider, or any person appearing or quoted in any advertisement or public service announcement for or on behalf of Honor Flight responsible for any injuries incurred by me while participating in the Honor Flight program. By checking this box and typing my name below, I am electronically signing my applicationUpload Signature here Choose File Date Signed Submit Form
