Veteran Application Online Form |
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Honor Flight Tri-State recognizes American Veterans for your sacrifices and accomplishments by flying you to Washington DC to visit your memorial at no cost. We are accepting applications from all war veterans, but are giving priority based on seniority. Terminally ill veterans get priority on all flights. It is our goal to provide you with a safe, memorable, and rewarding experience. To help us do that, we will provide Guardians to assist you with any and all of your needs throughout the day, and to provide you with a memorable experience. The information contained on this application is for the use of Honor Flight Tri-State only and will not be shared with anyone. If you have questions, please call us on our hotline - 513-277-9626.
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| Personal Information |
Have you seen your World War II Memorial?
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Have you been on an Honor Flight yet?
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Name
First Middle Last |
(As it appears on your photo ID for airline travel) |
Nick Name
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| Date of Birth |
Gender |
| Address |
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| (if needed) Address 2 |
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| City,State,Zip |
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| Daytime Phone |
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| Nightime Phone |
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| Cell Phone |
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| Email |
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| T-Shirt size |
Weight
Age |
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| Service History |
Branch of Service
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War
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| Draft/Enlistment date |
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| Activity during service |
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| Discharged date |
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| How did you hear about us? |
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| Companion Information |
Do you have a specific person that you'd like to have as your Guardian*?
* NOTE: Veterans' spouses are not eligible to be guardians
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| If Yes, Name Relationship |
| Guardian's Phone Age |
| Please note: If YES, A guardian application must be filled out the same time as this application. If NO, we will provide a trained guardian for you, from our database of Guardian personnel. All guardians must be between the ages of 18 and 67. |
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Do you want to travel with a specific Verteran/buddy?
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| If Yes, Name Phone |
| Please note: If you want to travel with another Veteran/buddy, please fill out your applications at the same time and note the other on each application. |
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| Medical Information |
So that we may assist you on your trip, please provide the following information. Information provided will not disqualify you. It permits us to assess the support we need to provide during the trip. Information is for Honor Flight Tri-State’s use only. Your signature on this page grants us the right share your information with our medical, flight and administrative staff.
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| Do you use mobility equipment?
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(Check all that apply)
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Can you go up and down 6 steps on a bus (this is a bus tour in DC with multiple stops) and walk down the aisle on the bus and plane?
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Would you like to have a wheelchair available for use during the day:
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You may not be totally wheelchair bound. You must be able to get on the bus and plane.
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Do you have a history of seizures?
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If yes, describe?
(i.e. grand mal, petit mal, other)
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When was your last seizure?
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If your seizure was within the last 5 years, we STRONGLY advise you discuss the trip with your private physician!
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| Do you have problems with motion sickness (sea or air)? |
| If you answered yes, is it controlled with medications? |
| Do you have any problems with flying in a commercial aircraft? |
| If your motion sickness is not controlled with medication, it is STRONGLY advised that you discuss the trip with your physician. |
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| Do you have any breathing problems? |
If yes, describe?
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| Do you use a home nebulizer machine? |
| If yes, we STRONGLY advise that you discuss the trip with your physician concerning the use of portable hand held nebulizers during the trip. |
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| Do you use oxygen at any time? |
If yes, your physician must write a prescription for oxygen to be used during the flight and during the tour. Oxygen will be provided by Honor Flight Tri-State. The prescription MUST be turned in as soon as possible.
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| Do you have a problem walking the length of a football field unassisted? |
If yes, please describe the reason
(i.e. lung problems, arthritis, heart problems, etc.)
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| Do you have history of head injuries, sinus problems, or ear problems? |
| If yes, have you flown since the problem occurred? |
| If yes, do you still have any problems? |
| If yes, it is STRONGLY advised you discuss the trip with your physician. If you have not flown since the problem occurred, again we STRONGLY advise that you discuss the trip with your physician. |
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| Do you have a draining catheter, urostomy or colostomy bag? |
| If yes, please make sure your bag is vented prior to flight, If you do not know if your bag is vented, you must discuss the issue with your physician. |
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| Do you have a feeding tube of any type?
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Do you have diabetes?
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If yes, is insulin injected or oral?
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Do your medication require refrigeration?
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Do you carry glucose with you?
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Medications:
(Name & How Often) |
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| Any other medical information that we should know about? Please explain |
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Disclaimer
I, the undersigned, acknowledge and agree that:
1. As photographic and video equipment are frequently used to memorialize and document Honor Flight Tri-State trips and events, my image may appear in a public forum, such as the news media or a website, to acknowledge or promote the work of the Honor Flight Tri-State Program. I hereby release the photographer and Honor Flight Tri-State from all claims and liability relating to said photographs. I hereby give my permission for my image captured during the Honor Flight Tri-State Activities through video, photos or other media, to be used solely for the purposes of Honor Flight promotional materials and publications, and waive any rights, compensation or ownership thereto.
2.I further understand that medical and trip insurance is the responsibility of the veteran. I also understand and agree that Honor Flight Tri-State does not provide medical care. I understand that I accept all risks associated with air and ground travel, and other Honor Flight Tri-State Activities and will not hold Honor Flight Tri-State responsible for any injuries incurred by me while participating in the Honor Flight Tri-State Program.
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I agree to the above
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(you may have to sign a release before the flight) |
Date
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Flight Schedule