Staff Medical Form

Staff Medical Form

Villages Honor Flight
The purpose of this form is to provide Villages Honor Flight and/or emergency medical personnel information about the participants, should an emergency arise. Please include all medical information requested.
Enter Mission Number:*
Name as it appears on photo ID (for TSA purposes)*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Don't forget Area Code
Land Line Phone Number
Include Area Code
Email Address*
example@example.com
Date of Birth:*

MonthDayYear
MM/DD/YYYY
Height*
Weight*
(lbs)
Do You Have Drug Allergies?*
Please List Your Drug Allergies Here.*
You may add as much information as needed the field will expand.
Do You Have Food Allergies?*
Please List Your Food Allergies Here.*
You may add as much information as needed the field will expand.
Do You Have Any Medical Conditions?*
Please List Your Medical Conditions Here.*
You may add as much information as needed the field will expand.
Do You Take Any Medications?*
Please List Your Daily Medications and Times Taken Here.*
You may add as much information as needed the field will expand.
Can You Walk 2 miles Easily, Pushing a Wheelchair?*
Which COVID vaccine did you receive?
Enter Date of first COVID vaccination.

MonthDayYear
Date
Enter Date of second COVID vaccination.

MonthDayYear
Date
Emergency Hospital Use- May release updated medical information to the following people: *
I hereby authorize Villages Honor Flight, its officers, employees, members, participants, users and/or volunteers, to take the action they believe is appropriate in an emergency situation. Further, I agree to indemnify and hold harmless Villages Honor Flight organization, any officer, employee, member, participant, user and/or volunteer thereof, against any claim(s) arising out of said emergency care.
Typing your name below constitutes your digital signature when sending via email.
Signature*
Today's Date*

MonthDayYear
Date
PRINT FORM if you desire then Click On SUBMIT.
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