Access Application Version: VHF Veteran Online Application

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Date Submitted

Villages Honor Flight, Inc. recognizes American veterans for their sacrifices and achievements by taking them to Washington, D.C. to see THEIR memorial at no cost. Top priority is given to WWII and terminally ill veterans from all wars. Volunteer Guardians will go along providing assistance and helping veterans have a safe, memorable and rewarding experience. Please note, Villages Honor Flight does not accept Veteran-Specific requests for Guardians (this includes family members as well). Appplicants for Honor Flight to Washington D.C. must be 80 years of age or above at time of application.

Villages Honor Flight, Inc. also recognizes there are veterans with physical limitations or who simply prefer not to fly so we offer a 'Flightless' Honor Flight alternative . Our 'Flightless' Honor Flight mirrors and matches the Washington D.C. Flight experience without the need to fly or endure the long day required for a Washington D.C. Honor Flight. Volunteer Guardians will go along providing assistance and helping veterans have a safe, memorable and rewarding experience. Please note, Villages Honor Flight does not accept Veteran-Specific requests for Guardians (this includes family members as well). There is no minimum age requirement for 'Flightless' Honor Flight.

For what you and your comrades have given to us, please consider this a small token of appreciation from Villages Honor Flight, Inc. The name and date of birth provided on this application must match the photo ID you will use on Flight Day.

For further information, please contact our Veteran Coordinator:

Mike Murphy at 602-295-8414
Email: veteran@villageshonorflight.org
Visit Website: https://villageshonorflight.org

I am applying for the following type of Honor Flight: *

I acknowledge I am 80 or Older and want to go on an Honor Flight Mission to Washington D.C. I am applying for 'Flightless' Honor Flight.

Nickname (How you prefer to be addressed).

Name as it appears on photo ID (for TSA purposes) *

First Name Middle Name Last Name Suffix

Date of Birth *

Enter Date of Birth

Date of Birth *

MUST BE 80 YEARS OF AGE OR ABOVE

Gender *

Select

Select Height: *

Select Height

Weight: *

(in pounds)

Address *

Street Address

City State

Zip Code

Daytime Phone Number *

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Email

example@example.com

Branch of Service: *

Select Branch

Rank: *

When/Where Served? *

Location and date

Home Town (when you entered the Service) *

City & State

Activity during service period. *

TSA Approved Photo ID Type *

Enter TSA Approved ID Type

State

Enter TSA ID Issuing State if Applicable

Expiration Date

Expiration Date of TSA ID if Applicable

1st Emergency Contact Name: *

First Name Last Name

Relationship: *

1st Emergency Contact Phone Number *

Area Code Phone Number

1st Emergency Contact Address *

Street Address

Street Address Line 2

City State

Zip Code

Alternate Emergency Contact Name *

First Name Last Name

Relationship: *

Alternate Emergency Contact Phone Number *

Area Code Phone Number

Alternate Emergency Contact Address

Street Address

Street Address Line 2

City State

Zip Code

Please Select Shirt Size: *

Small Medium Large X Large XX Large

Veterans are permitted to take part in one (1) Honor Flight to help us make sure all Veterans have an opportunity to take part in the program. Please acknowledge your understanding. *

I have NOT been on an Honor Flight.

How did you hear about Honor Flight?

MEDICAL INFORMATION

Information provided will not disqualify you. It permits us to assess the support we need during the trip. Inormation is for Villages Honor Flight Medical Personnel only.

*DISCLAIMER: Wheelchairs with 250 lb. maximum weight limit are provided for each Veteran and may be required during certain portions of the HF trip.

Do you use MOBILITY EQUIPMENT? *

Cane Walker Wheelchair* Scooter Not Needed

Medications (include how often you take this medication) *

EXAMPLE SHOWN with name of medication and how often taken. PLACE EACH MEDICATION ON A NEW LINE.

Do you have any DRUG ALLERGIES? *

YES NO

If yes, list drugs and type of allergic reaction.

Do you have a history of seizures? *

Yes No

If yes, please describe the type:

grand Mal petite Mal

When was your last seizure?

within past year within 2 years within 5 years

If you have had any type of seizure within past 5 years, it is STRONGLY advised that you discuss trip with your private physician.

Do you have motion sickness (sea or air)? *

Yes No

If motion sickness is not controlled by medications, you are STRONGLY encouraged to discuss the trip with your private physician.

Do you have any breathing problems? *

Yes No

Describe type of breathing problems.

Do you use a home nebulizer machine?

Yes No

If you use a home nebulizer machine 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 No

If you use oxygen you will be required to provide your own airline approved POC (personal oxygen concentrator) and your physician will need to write a prescription for the oxygen to be used during the flight and tour which should be turned in with your application. Oxygen will not be provided by Honor Flight and liquid oxygen is strictly prohibited for use on airplanes.

What is the delivery rate?

LPM

BRAND NAME OF POC

Do you have a problem walking the length of a football field without assistance? *

Yes No

If you have a problem walking without assistance, please describe the reason, i.e. lung problems, arthritis, heart problems, etc....

How many blocks can you walk before getting tired? *

Select one

Can you climb 6 steps on to a bus and walk down its aisle? *

Yes No

Have you ever been told, or do you believe, you have PTSD? *

Yes No

Are you diabetic? *

Yes No

Do you take insulin for your diabetes? *

Yes No

Do you have a pacemaker? *

Yes No

Do you have a defibrillator? *

Yes No

Do you have prosthetics? *

Yes No

Check the box if you have a history of any of the following.

Open Head Injury Sinus Problems Ear Problems

Do you still have head, ear, or sinus problems?

Yes No

If you have NEVER flown since the open head injury, sinus or ear problems, we STRONGLY encourage you to discuss the trip with your private pysician.

Do you have a uostomy or colostomy bag? *

Yes No

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:

PLEASE REVIEW CAREFULLY AND SIGN.

I hereby give permission for my images to be taken or captured during Villages Honor Flight, Inc. trip through video, photo, or other media, to be used solely for the purposes fo Villages Honor Flight, Inc. promotional material and publications, and waive any rights or compensation or ownership thereto.
I understand that medical insurance is the responsibility of the veteran and that Villages Honor Flight, Inc. does NOT provide medical care. I understand that I accept all risks associated with travel and other Villages Honor Flight, Inc. activities and will not hold Villages Honor Flight, Inc., any staff, volunteers, or other Villages Honor Flight representatives responsible for any injuries incurred by me while participating in the Villages Honor Flight Inc. program.

Typing your name below constitutes your digital signature when sending via email.

Signature *

Please type your name

When completed, select PRINT FORM for your own records and then select SUBMIT,

OR if you encounter problems mail a copy of the printed form to:

Villages Honor Flight, Inc.
Attn: Veteran Application
PO Box 490
Lady Lake, FL 32158-0490

VHF VETERAN APPLICATION

EMERGENCY CONTACTS