Veteran Application

Honor Flight recognizes America’s veterans for their sacrifices and achievements by flying them to Washington, DC to see YOUR memorial at no cost. Please consider this a small token of appreciation from all of us at Honor Flight. To be added to our waiting list, please complete, and submit the application. For further information, please call (631) 702-2423.

We won't call you when we receive your application, we will contact you when it's your turn.

YOUR NAME (As it appears on your ID for airline travel)

NICK NAME (If applicable)

Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP

CELL

HOME PHONE

E MAIL ADDRESS

example@example.com

DATE of BIRTH

Date

Have your been a part of Honor Flight bfore?

YesNo

T SHIRT SIZE: (S. M. L. XL, XXL, XXXL)

APPROXIMATE WEIGHT

WAR CONFLICT

WWIIKOREANVIETNAM / VIETNAM ERAOther

APPROXIMATE HEIGHT

SERVICE BRANCH

RANK

ACTIVE SERVICE DATES and LOCATION

Do you have someone who would serve as your guardian? (Please note that spouses may not serve as guardians, they must be next generation and able bodied)

YesNo

Guardian's Name

First NameLast Name

Guardian's Phone Number

Please enter a valid phone number.

We strongly recommend that Veterans do NOT drive themselves on Flight Day!! Do you know someone who will provide your transportation to and from the airport?

NoYes, Please provide the name of driver

ALTERNATE CONTACT NAME (son, daughter, etc):

ALTERNATE CONTACT RELATIONSHIP

ALTERNATE CONTACT PHONE

ALTERNATE CONTACT E-MAIL

example@example.com

EMERGENCY CONTACT INFORMATION
(someone available back on Long Island or at where you live the day that you travel)

Name

Relationship

CELL

HOME PHONE

HOW DID YOU HEAR ABOUT HONOR FLIGHT?

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?

YesNo

Do you use mobility equipment? (Check Device used)

Do you have any drug allergies?

YesNo

If yes, please list (drug allergies)

Do you have a history of seizure?

YesNo

If Yes, please describe what type (i.e. grand mal, petit mal, other)

When was your last seizure? If within past 5 years, please discuss trip with your private physician!

Do you have problems with motion sickness (sea or air)?

YesNo

If yes, is it controlled with medications?

YesNo

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?

YesNo

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.

YesNo

Do you use oxygen at any time? If YES, please note you will need to obtain a portable oxygen concentrator and extra batteries. You will also need a prescription from your medical provider ordering the oxygen use. *You cannot use liquid oxygen or compressed gas, *There are companies who rent portable oxygen concentrators, and Medicare will often cover part of the cost. *Inogen is a company frequently used for portable oxygen concentrator rental and purchases. You can find them online at try.inogen.com or by calling 1 877-380-4857 *It is also advised to check with your local medical supply store**Please ensure you have adequate oxygen/batteries for 24 hours in order to plan for any unforeseen flight delays/ cancellations*

YesNo

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.):

NOYES (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?

YesNo

If YES, have you flown since the open head injury, sinus or ear problems occurred?

YesNo

If YES, did you have any problems? 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.

YesNo

Do you have an ostomy bag? If YES, please make sure the bag is vented prior to flight. If you do not know if your bag is vented, PLEASE discuss this issue with your private physician.

YesNo

Additional Medical Comments or Concerns

PLEASE REVIEW CAREFULLY AND SIGN:

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 or complications resulting from a medical event while participating in the Honor Flight program.

SIGNED*

DATE

Date

PLEASE NOTE: We will not call you until it's your turn to fly;
however, you are invited to call us anytime.

(631) 702-2423

Honor Flight Long Island c/o Jamie Bowden
116 Hampton Road Southampton, NY 1196

Email: jbowden@southamptontownny.gov
www.honorflightlongisland.org