Veteran Application

We recommend clicking on this link to get the Veteran Application. If the link does not work, you can print the application below. You might need additional pieces of paper for your application. If you still cannot print the application call: Beth Bouley at (218)779-7834 and she will mail you the application.

FOR HONOR FLIGHT USE ONLY Last Name: ___________________________ Date Received: ________________

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 will be given to those World War II Veterans who haven’t yet seen their memorial followed by Korean War Veterans and terminally ill Veterans from all wars. In order for Honor Flight to achieve this goal, escorts fly with the Veterans on every flight providing assistance and helping them have a safe, memorable and rewarding experience. Please consider this a small token of appreciation from all of us at WDAY Honor Flight for what you and your comrades have given to us. For further information, please contact us at (218) 779-7834 or visit us at www.wdayhonorflight.areavoices.com

All applications are taken in the order received with the exception of terminally ill veterans who may be from any American war or conflict. We will be contacting you by mail when there is a seat available for you on our next flight.

 

YOUR NAME: __________________________________________________________

(As it appears on your ID for airline travel)

NICK NAME: ____________________

(If Applicable)

DATE OF BIRTH____________________

ADDRESS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CITY: _________________________________________ STATE: ________ ZIP: ________________

PHONE: Day: _______________________ Evening: _________________________

Cell: _______________________

E-MAIL ADDRESS: _________________________________________________

AGE: ___________                    T-SHIRT SIZE: (S, M, L, XL, XXL, XXXL) ____________

ALTERNATE CONTACT INFORMATION (son, daughter, etc):

NAME: ________________________________________________________

PHONE: Day: _______________________ Evening: __________________________

Cell: _________________________________

EMAIL: _________________________________ RELATIONSHIP: __________________________________________

EMERGENCY CONTACT INFORMATION (someone available the day you travel):

NAME: ___________________________________________________________________

RELATIONSHIP: ___________________

ADDRESS: ______________________________________________________________________________________________________________________________________________________

PHONE: Day: ____________________ Evening: ______________________Cell: ___________________________________________________________________________SERVICE HISTORY: BRANCH OF SERVICE: _____________________RANK: _________________________________________

Which war/conflict are you a veteran of?   _______________________________________________________________________

HOME TOWN (city and state where you grew up):_________________________________________________

Where do you live now?  _____________________________________________________________________

What years did you serve? Approximate dates if you are uncertain ___________________________________________________________

ACTIVITY:

Where did you take your Basic Training/Boot Camp? __________________________________________________________________________

Do you recall which unit, company, fleet, division etc. you served in? __________________________________________________________________________

Where were you stationed? ______________________________________________________________________________________________________________________________________________________

What was the specific job or duty you were assigned to? __________________________________________________________________________

What was your “proudest moment,” or biggest accomplishment while in the service? ______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________

What did you do after the   military?______________________________________________________________________________________________________________________________________________

TELL US ABOUT YOUR LIFE AFTER YOUR SERVICE: (example-jobs, family, and children)

Attach separate sheet as needed: _______________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you belong to a service organization now?  If so, which one?______________________________________

Location of service organization: _______________________________________________________________

 

 

MEDICAL: THIS INFORMATION IS NECESSARY SO WE MAY PROVIDE YOU WITH THE APPROPRIATE MEDICAL SUPPORT DURING YOUR TRIP. THIS INFORMATION IS FOR HONOR FLIGHT AND MEDICAL PERSONNEL ONLY. YOUR RESPONSES TO THESE QUESTIONS WILL NOT AFFECT YOUR ELIGIBILITY. OUR MEDICAL TEAM THAT WILL BE WITH US ON THE TRIP MAY ASK TO VISIT WITH YOUR PHYSICIAN IF THERE ARE ANY CONCERNS.

Do you use mobility equipment, even for brief periods of time? YES     NO

Can you walk a mile without any assistance? YES   NO

If YES, please circle device: CANE  WALKER  WHEELCHAIR  SCOOTER

MEDICATIONS YOU USE

MEDICATION NAME                                                  HOW OFTEN IS IT TAKEN?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(If more room is needed for medications, please continue on an additional sheet of paper)

  1. List any drug allergies? (Please list)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. List any food allergies? (Please list)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. Do you have a history of seizures? YES   NO

Please describe what type (i.e. grand mal, petit mal, other) ___________________________________________

When was your last seizure? _________________________ If within the past 5 years, we STRONGLY advise you discuss trip with your private physician!

  1. Do you have problems with motion sickness (car 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!

  1. Do you have any breathing problems? YES   NO. If YES, please describe: _______________________________
  2. 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.
  3. 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 tanks cannot be used on aircraft. Oxygen will be provided by the Honor Flight committee once we arrive in Washington DC. The prescription MUST be turned in with the application.
  4. 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.):_________________________________
  5. 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, we STRONGLY advised you discuss the trip with your private physician. If you have NOT flown since the open head injury, sinus or ear problems, again we STRONGLY advise you discuss the trip with your private physician.

  1. 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.

Honor Flight realizes the veterans may need assistance for such things as wheelchairs, medications etc. You may bring your own family member escort to assist you on the trip; however there is a fee for an escort to travel with you. This escort MUST be capable of handling all luggage and able to push your wheelchair if needed. Unfortunately, The Honor Flight Network guidelines, which we are required to follow, state that non-veteran spouses are unable to serve as an escort (except in a rare medical necessity). There will be assistance available on the trip to aid those veterans who may need a little extra help getting around. We strongly recommend that you have an escort if you feel you need to as we want this to be a wonderful and meaningful experience for you.

Please do not bring an escort if you do not need one. We would like as many Veterans to participate as possible and we do not want to take the seat of a Veteran away for an escort unless needed.

  1. Do you need a family member escort for mobility or medical reasons? YES   NO.

If YES, please describe the reason: _____________________________________________________________

__________________________________________________________________________________________

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 to Forum Communications Company to publish my images and/or biographical information 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 Honor

Flight does NOT provide medical care. I understand that I accept all risks associated with travel and other Honor Flight activities and will not hold Honor Flight responsible for any injuries incurred by me while participating in the Honor Flight program

SIGNATURE OF VETERAN: __________________________________________________________________

DATE: _______________________

Please submit this form to:

WDAY Honor Flight

Melvin E. Hearl American Legion Post 21

303 30th St. N

Moorhead, MN 56560
ANY QUESTIONS, CALL (218) 779-7834 or www.wdayhonorflight.areavoices.com

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