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2000 75th Street West, Bradenton, FL

Kirby Stewart Post 24

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                         KIRBY STEWART POST 24

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                                               HONOR  FLIGHT     

 
PAGE 2........VETERAN application for SOUTH WEST FLORIDA
 
PAGE 3........GUARDIAN application for SOUTH WEST FLORIDA
 
                                             
_____________________________________________________________________ 
                                                  
 
 
 
Contact HONOR FLIGHT @ www.honorflight.org    
 
 
 
FOR HONOR FLIGHT USE ONLY L N: _________________________
D R: __________/___________/__________
 
 
Veteran Application
  
Honor Flight recognizes American veterans for your sacrifices and achievements by flying you to Washington, DC to see YOUR memorial at no cost. Top priority (for which we are currently accepting application only) is given to WW II and terminally ill veterans from all wars. In the future, Honor Flight will be expanded to include Korean and Vietnam veterans. In order for Honor Flight 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 at Honor Flight. For further information, please contact us a (937) 521-2400.
YOUR NAME: __________________________________ NICK NAME: ____________________
(Please List Your First, Middle & Last Name as it appears on your driver's license or government ID.) (If Applicable)
ADDRESS: ______________________________________________________GENDER:___M/F
CITY: ____________________ COUNTY:____________ STATE: ________ ZIP: __
PHONE: Day: _______________________ Evening: ___________ Cell Phone: ________
E-MAIL ADDRESS: ________________________________ WEIGHT: _________ AGE:_______DOB:____________
HOW DID YOU HEAR ABOUT HONOR FLIGHT? __________________________________________________________ _______________________________________________________.                                    TEE SHIRT SIZE: (S, M, L, XL, XXL, XXXL) _______
PREFERRED DEPARTING AIRPORT:_________________________
ALTERNATE CONTACT (son, daughter, etc): NAME: ________________________________________________________
PHONE: ____________ E-MAIL:___________________________ RELATIONSHIP: _________________________
EMERGENCY CONTACT INFORMATION (someone available the day you travel):
Name: ___________________________________________________________________ Relationship: ___________________
Address: ___________________PHONE: Day: ______________________ Evening: __________________________ Mobile: ___________________________
SERVICE HISTORY: BRANCH OF SERVICE: ___________ RANK: ____________
 HOME TOWN (from which city and state did you enter the service?):________________________________________________
ACTIVITY DURING WWII: _________________________________________________________________
__________________________________________________________________
MEDICAL: 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? YES NO. If YES, please circle device: CANE WALKER WHEELCHAIR SCOOTER
MEDICATION TAKEN HOW OFTEN? MEDICATION TAKEN HOW OFTEN?
____________________ ___________________________ ____________________ ____________________
____________________ ___________________________ ____________________ ____________________
____________________ ___________________________ ____________________ ____________________
____________________ ___________________________ ____________________ ____________________
PLEASE COMPLETE BACK PAGE
Do you have any drug allergies? ____________________________________________________________________
Do you have a history of seizure? YES NO Please describe what type (i.e. grand mal, petit mal, other) _________________. When was your last seizure? _________. If within past 5 years, STRONGLY advised you discuss trip with your private physician!
Do you have problems with motion sickness (sea or air)? YES NO. If yes, is it controlled with medications? YES NO
If motion sickness is not controlled with medications, it is STRONGLY advised you discuss the trip with your private physician!
Do you have any breathing problems? YES NO. If YES, please describe: __________________________________________
Do you use a home nebulizer machine? YES NO. 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 use oxygen at any time? YES NO. If YES, you will need your private physician to write a prescription for oxygen to be used during the flight and during the tour. Oxygen will be provided. The prescription should be turned in with the application.
Do you have a problem walking the length of a football field without assistance? YES NO. If yes, please describe the reason (e.g. lung problems, arthritis, heart problems, etc.):_______________________________________________________________
Do you have a history of open head injuries, sinus problems, or ear problems? YES NO. If YES, have you flown since the open head injury, sinus or ear problems occurred? YES NO. If YES, did you have any problems? YES NO
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? YES NO. 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.
Additional Comments or Concerns: ___________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
PLEASE REVIEW CAREFULLY AND SIGN:
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 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.
SIGNED: ____________________________________________
DATE: _____/_____/______ (E-mail applicants will be required to sign prior to actual flight date)
Please submit this form to: Honor Flight, Inc.
ATTN: Veteran Application
300 E. Auburn Ave.
Springfield, OH 45505-4703

Or fax to: (937) 521-2580 or (937) 521-2512

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