Honor Flight Houston recognizes American veterans for your achievements and sacrifices by flying you to Washington, D.C. to see your memorial at no cost. Top priority is given to WWII and terminally ill veterans from all wars. Currently, Honor Flight Houston is accepting applications for WWII, Korean and Vietnam War veterans. 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 Houston. For further information, please contact us at 713-565-2685 or visit us at www.HonorFlightHouston.org
YOUR NAME:
NICKNAME:
STREET ADDRESS:
CITY:
COUNTY:
STATE:
ZIP:
HOME PHONE:
CELL:
OTHER:
EMAIL ADDRESS:
DATE OF BIRTH:
AGE:
WEIGHT:
Gender: MF
*Tee Shirt Size:SMLXL2X3X
World War IIKoreaVietnamOther:
Branch of Service:
Rank:
Dates Server: From:
To:
Activity During Service (Including Where Served):
Medals/Commendations/Recognitions:
Have you flown with an Honor Flight prior to applying with Honor Flight Houston?YesNo [group flownbefore] If Yes, which hub? [/group]
Do you have a preferred Guardian*? YesNo [group preferredguardian] If Yes, Name & Relation[/group]
*Family Guardians may be placed as medically needed, however we cannot guarantee Guardian placement
Name:
Relationship:
Street Address:
City:
State:
Zip:
Cell:
Home:
Other:
Email:
PHONE: Cell:
Do you use mobility equipment? YesNo
[group mobility]
If Yes: CaneWalkerWheelchair
[/group]
Do you smoke cigarettes? YesNo
MEDICATION TAKEN?
HOW OFTEN?
Do you have a Pacemaker? YesNo
Defibrillator? YesNo
Prosthetics? YesNo
Are you diabetic? YesNo
[group diabetic]
If yes, do you take insulin? YesNo
[/group] [group insulin]
Self-Inject? YesNo
Any drug allergies? YesNo
[group drug]
If Yes, please list:
Any food allergies or dietary needs? YesNo
[group food]
Do you have any breathing problems? YesNo
[group breathing]
If Yes, please describe:
[group oxygen]
Do you use oxygen at any time? YesNo
[/group] [group oxygen2]
If Yes, do you use it: Full timeNight onlyAs Needed
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? YesNo
[group walking]
If yes, please describe reason (e.g. lung problems, arthritis, heart problems, etc...):
Are you currently taking medication for dementia and/or Alzheimer’s? YesNo
Do you have a history of seizure?YesNo [group seizure] If Yes, what type (i.e. grand mal, petit mal, other): [/group]
When was your last seizure? If within past 5 years, STRONGLY advise discussing trip with your private physician.
Do you have any problems with motion sickness (sea or air)? YesNo [group motion] If Yes, is it controlled with medications? YesNo [/group]
If motion sickness is not controlled with medications, it is STRONGLY advised discussing the trip with your private physician
Do you have a urostomy or colostomy bag? YesNo [group urostomy] 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. [/group]
Do you have a history of open head injuries, sinus problems, or ear problems? YesNo [group history] If Yes, have you flown since the open head injury, sinus or ear problems? YesNo [group flown] If Yes, did you have any problems? YesNo [group flown2] If Yes, we STRONGLY advise you discuss the trip with your private physician. If you have NEVER flown since the open head, sinus [/group] [/group] [/group]
Additional Comments or Concerns:
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 advertise-ment 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.
Signature:
Date:
