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Veteran Application
Your Name(*)
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Nickname (if applicable)
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Gender(*)
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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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Date of Birth(*)
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How did you hear about Honor Flight?
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T-Shirt Size(*)
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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 Korean or Vietnam Wars
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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?(*)
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If yes, please select the device:
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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?(*)
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If yes, please describe them
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Do you have a history of seizure?(*)
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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)(*)
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If yes, is it controlled with medication?
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Do you have any breathing problems?(*)
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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)(*)
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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) (*)
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Do you have a problem walking the length of a football field without assistance?(*)
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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?(*)
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If yes, have you flown since the open head injury, sinus or ear problem occurred?
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If yes, did you have any problems?
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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?(*)
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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.
Do you have any nighttime confusion?(*)
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Your primary physician's name(*)
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Your primary physician's phone number(*)
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Please list any additional comments or concerns
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Please carefully review and then check the box(*)
you must check the box
Please carefully review and then check the box(*)
You must check the box
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