Veteran Application

Veteran Application
Honor Flight of Central Oregon recognizes Korean War Veterans for your sacrifices and achievements by flying you to Washington, D.C. to see YOUR memorial at no cost. In addition, top priority is given to WWII and terminally ill veterans from all wars. In order for Honor Flight of Central Oregon to achieve this goal, guardians fly with the veterans on every flight providing assistance and helping veterans have a safe, memorable and rewarding experience. For what you and your comrades have given to us, please consider this a small token of appreciation from all of us.
YOUR NAME
(Use your full name as it appears on your driver's license or government ID)
NICKNAME
ADDRESS
CITY
COUNTY
STATE
ZIP
Best time to contact

DayEvening
Cell
EMAIL
example@example.com
AGE
DOB
WEIGHT
Gender

FemaleMale
IS THERE A SPECIFIC GUARDIAN YOU WISH TO TRAVEL WITH YOU?

YesNo
If YES, what is his/her name?
Relationship to you?
HOW DID YOU HEAR ABOUT HONOR FLIGHT?
T SHIRT SIZE: (S,M,L,XL,2XL,3XL,4XL)
Have you ever received a Quilt of Valor?

YesNo
ALTERNATE CONTACT
NAME
RELATIONSHIP
PHONE
E MAIL
example@example.com
EMERGENCY CONTACT INFORMATION (Someone available on the day you travel)
NAME
RELATIONSHIP
Address

ADDRESS

Street Address Line 2

CitySTATE

Postal / Zip Code
PHONE: DAY
EVENING
CELL
SERVICE HISTORY
BRANCH OF SERVICE
RANK
SERVICE DATES

MonthDayYear
Date
HOMETOWN: (City and State from which you entered the military)
ACTIVITY DURING SERVICE
Medical

THE 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
IF YES, PLEASE CIRCLE: CANE I WALKER I WHEELCHAIR I SCOOTER | OTHER
Medication
List your medication and frequency
Do you have any Drug Allergies?

YesNo
If yes, please describe
Do you have a history of seizures?

YesNo
If YES, please describe (grand mal, petit mal, other)
If you have had a seizure within the last 5 years, it is strongly advised to discuss travel with your doctor
When was your last seizure?
Do you get motion sickness? (sea, air, vehicle)Sea

YesNo
If YES, is it controlled with medication?

YesNo
Do you have any breathing problems?

YesNo
If YES, please describe
Do you use a Home Nebulizer?

YesNo
Do you use oxygen at any time?

YesNo
If YES, you will need an oxygen prescription from your doctor to be able to use oxygen during the trip. Oxygen will be provided. The prescription should be included with the application.
Do you have a problem walking the length of a football field without assistance?

YesNo
If YES, please describe (e.g., heart or lung problems, arthritis, etc.)
Do you have a history of open head injuries, sinus problems, or ear problems?

YesNo
If YES, have you flown since the problem?

YesNo
If Yes, did you have any problems flying?

YesNo
Do you have a urostomy or colostomy bag?

YesNo
If YES, please ensure the bag is vented prior to flight.
ADDITIONAL COMMENTS OR CONCERNS
** IF YOU ANSWERED YES TO ANY OF THE MEDICAL QUESTIONS, YOU ARE STRONGLY ADVISED TO DISCUSS THIS TRIP WITH YOUR DOCTOR**
Do you have any food restrictions?
PLEASE REVIEW CAREFULLY:
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 neither Honor Flight nor the provider of free private aircraft ("Flight Provider") provides medical care. I understand thatI accept all risks associated with travel and other Honor Flight Network activities and will not hold Honor Flight, theFlight Provider, or any person appearing or quoted in any advertisement or public service announcement or on behalf of Honor Flight responsible for any injuries incurred by me while participating in the Honor Flight
SIGNED

Clear
DATE

MonthDayYear
Date
Should be Empty:

Veteran Application

ALTERNATE CONTACT

SERVICE HISTORY

Medical

Medication

** IF YOU ANSWERED YES TO ANY OF THE MEDICAL QUESTIONS, YOU ARE STRONGLY ADVISED TO DISCUSS THIS TRIP WITH YOUR DOCTOR**

PLEASE REVIEW CAREFULLY:

IF YOU ANSWERED YES TO ANY OF THE MEDICAL QUESTIONS, YOU ARE STRONGLY ADVISED TO DISCUSS THIS TRIP WITH YOUR DOCTOR