Contact Information

First Name Middle Initial Last Name Nickname Gender Male Female Address City State AKALARASAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWY Zip Email Address Day Phone Alternative / Cell Phone Date of Birth (Format: Month-Day-Year)
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Medical History

Would you need assistance walking the length of a football field? Yes Can you walk up 7 bus steps with assistance? Yes Do you use mobility equipment? Yes What do you use? Cane Walker Wheelchair Scooter Please describe when you use mobility equipment Medication List (name and how often you use each) Dietary Restrictions / Considerations Check if you have any of the following COPD, Emphysema, Asthma Use a CPAP machine Inhaler or nebulizer use Heart disease, chest pain Pacemaker, defibrillator, heart attack Stroke Kidney / renal disease Urinary elimination problems Seizures History of falls, dizziness, fainting Joint replacement Diabetes Urostomy, colostomy Dementia, memory loss, Alzheimer's Use oxygen at any time? Yes How often do you use oxygen and flow rate? Other health concerns:

General Information

Weight (In Pounds, Numbers Only) How did you hear of Honor Flight? T-Shirt Size S M L XL XXL XXXL

Alternate Contact Information

Name Phone Email Relationship

Emergency Contact Information (someone available at home the day you travel)

Name Relationship Address Day Phone Cell Phone

Service History

Branch of Service Rank Service/Conflict Timeframe WW-II: Dec. 7, 1941 to Dec. 31, 1946 Korean War: June 25, 1950 to Jan. 31, 1955 Vietnam War: Feb. 28, 1961 to May 7, 1975 Other/Operations Other Than War Hometown of Record – (City/State where you lived when you entered service) Years of service Activity during your service

Additional Information

Are there other veterans you want to travel with? Yes Please list Vet's names Would you like to travel with a specific guardian?

*Guardians must be between the ages of 18 and 70 and need to complete a guardian application separately

Guardian Name Guardian Relationship Guardian Phone Number Additional Comments

Terms and Agreement

I Agree to the Terms below