Honor Flight Savannah | Veteran Application

Your Name (*)

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Nickname (if applicable)

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Gender (*)

MF

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Address (*)

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County (*)

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City (*)

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State (*)

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Zip Code (*)

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Phone (Day) (*)

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Phone (Evening)

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Phone (Cell)

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Email (*)

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Weight (*)

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Age (*)

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DOB (mm.dd.yyyy) (*)

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How did you hear about Honor Flight?

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T-Shirt Size (*)

SMLXLXXLXXXL

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Preferred Departing Airport

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Preferred Alternate Contact (Son, Daughter, etc.)

Name (*)

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Phone (*)

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Email

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Relationship (*)

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Emergency Contact Information (someone available to be reached on the same days you travel)

Name (*)

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Relationship (*)

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Address (*)

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Phone (Day) (*)

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Phone (Evening)

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Phone (Cell)

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Service History

Branch of Service (*)

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Rank (*)

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Hometown (city and state where you entered service) (*)

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Dates of Service (*)

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Activity During WWII or Korean War

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MEDICAL - Information will not disqualify you. It permits us to assess the support we need during the trip. Information is for Honor Flight and medical personnel only.

Do You Use Mobility Equipment? (*)

YN

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If yes, please select the device:

CaneWalkerWheelchairScooter

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Medication

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Taken How Often?

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Medication

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Taken How Often?

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Medication

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Taken How Often?

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Medication

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Taken How Often?

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Medication

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Taken How Often?

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Medication

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Taken How Often?

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Do you have any drug allergies? (*)

YN

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If yes, please describe them

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Do you have a history of seizure? (*)

YN

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

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When was your last seizure? (if within the past 5 years, you are STRONGLY advised to discuss your trip with your physician)

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

YN

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If yes, is it controlled with medication?

YN

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Do you have any breathing problems? (*)

YN

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If yes, please describe

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Do you use a home nebulizer machine? (if yes, you are STRONGLY advised to discuss the use of portable hand-held nebulizers during the trip with your physician) (*)

YN

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Do you use supplemental oxygen at this time? (if yes, you MUST have your physician write a prescription for oxygen to be used during the flight and tour. Oxygen will be provided. The prescription should be turned in ASAP following your completion of this application) (*)

YN

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

YN

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If yes, please describe the reason (e.g. lung problems, arthritis, heart problems, etc.)

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Do you have a history of open head injuries, sinus problems or ear problems? (*)

YN

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If yes, have you flown since the open head injury, sinus or ear problem occurred?

YN

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If yes, did you have any problems?

YN

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If yes, it is STRONGLY advised that you discuss your trip with your physician. If you have NEVER flown since your problems occurred, again we STRONGLY advise that you discuss your trip with your physician.

Do you have a urostomy or colostomy bag? (*)

YN

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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 physician.

Please list any additional comments or concerns

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Please carefully review and then check the box (*)

As photographic and video equipment are frequently used to memorialize and document Honor Flight trips and events, I understand that my 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 purpose of Honor Flight promotional material and publications, and waive any rights or compensation or ownership thereto.

you must check the box

Please carefully review and then check the box (*)

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 that I accept all risks associated with travel and other Honor Flight Network activities and will not hold Honor Flight, the Flight Provider, or any person appearing or quoted in any advertisement or public service announcement for or on behalf of Honor Flight responsible for any injuries incurred by me while participating in the Honor Flight program.

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