War(s) Fought
*
In which war(s) did you serve? Check all that apply to you.
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Weight
*
Date of Birth
*
MM
DD
YYYY
Home Phone
(###)
###
####
Mobile Phone
*
(###)
###
####
Name
*
Relationship to Applicant
*
Email
*
Phone
*
(###)
###
####
Name
*
Relationship to Applicant
*
Email
*
Phone
*
(###)
###
####
Branch
*
Theater
*
Activities During Military Service
Medical Equipment Used
*
Please check all that apply.
Do you use oxygen at any time?
*
If YES, oxygen will be provided during the flight and tour of Washington, D.C. as needed.
Do you have any drug allergies?
*
Comments
If YES, please list below.
Do you have a history of seizure?
*
Comments
If YES, please describe in the form below:
a) What type (grand mal, petit mal, etc.)?
b) When was your last seizure?
NOTE: If a seizure has occurred in the last five (5) years, it is STRONGLY advised you discuss the trip with your private physician!
Do you have problems with motion sickness (sea or air)?
*
If YES, please state in the form below whether it is controlled through medication.
NOTE: If motion sickness is not controlled with medications, it is STRONGLY advised you discuss the trip with your private physician!
Comments
Do you use a home nebulizer machine?
*
NOTE: 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.
Do you have a problem walking the length of a football field without assistance?
*
Do you have a history of open head injuries, sinus problems, or ear problems?
*
Comments
If YES, please state in the form below if you have flown since the open head injury, sinus, or ear problems occurred. 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.
Do you have a urostomy or colostomy bag?
*
NOTE: 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.
Do you have a pacemaker?
*
Are you a diabetic?
*
Do you have any special dietary needs/requirements?
*
Comments
If YES, please explain in the form below.
Additional Comments or Concerns
Have you ever flown on an Honor Flight at any time in the past, with any Honor Flight organization?
*
Date of Signature
*
MM
DD
YYYY
