Have you flown with an Honor Flight prior to applying with Honor Flight Houston?
If Yes, which hub?
Do you have a preferred Guardian?
If Yes, Name & Relation
* Family Guardians may be placed as medically needed, however we cannot guarantee Guardian placement
Emergency Contact Information
(Someone available the days you are traveling)
(Son, Daughter, etc... Please DO NOT list the same person above)
(Information provided will not disqualify you. It permits us to assess the support we need during the trip. Info is for Honor Flight Houston and Medical Personnel only.)
Do you use mobility equipment?YN
If Yes: CaneWalkerWheelchair
Do you smoke cigarettes?YN
Do you have a Pacemaker?YN
Are you diabetic?YN
If yes, do you take insulin?YN
Any drug allergies?YN
If Yes, please list:
Any food allergies or dietary needs?YN
If Yes, please list:
Do you have any breathing problems?YN
If Yes, please describe:
Do you use oxygen at any time?YN
If Yes, When do you use it:
What is the delivery rate (LPM)?
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?YN
Are you currently taking medication for dementia and/or Alzheimer’s?- YN
Do you have a history of seizure?YN
If Yes, what type (i.e. grand mal, petit mal, other):
When was your last seizure?
*If within past 5 years, we STRONGLY advise discussing trip with your private physician.*
Do you have any problems with motion sickness (sea or air)? YN
If Yes, is it controlled with medications?
Do you have a urostomy or colostomy bag?YN
*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 your discuss this issue with your private physician.*
Do you have a history of open head injuries, sinus problems, or ear problems? YN
If Yes, have you flown since the open head injury, sinus or ear problems? YN
If Yes, we STRONGLY advise you discuss the trip 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 Houston 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 Houston program. I hereby release the photographer and Honor Flight Houston from all claims and liability relating to said photographs. I hereby give permission for my images captured during Honor Flight Houston activity through video, photo, or other media to be used solely for the purposes of Honor Flight Houston 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 Houston 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 Houston activities and will not hold Honor Flight Houston, the Flight Provider, or any person appearing or quoted in any advertisement or public service announcement for or on behalf of Honor Flight Houston responsible for any injuries incurred by me while participating in the Honor Flight Houston program.