Fillable Honor Flight Chicago Veteran Application Honor Flight Chicago

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Honor Flight Chicago Veteran Application Honor Flight Chicago

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The Honor Flight Chicago Veteran Application Honor Flight Chicago form is 3 pages long and contains:

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  • 42 check-boxes
  • 96 other fields

Country of origin: OTHERS
File type: PDF

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Page 1 of 3
Honor Flight Chicago
honorightchicago.org
Veteran Application - 2020
12/1
9
Your name: _____________________________________ Nickname: ______________________
Address: _______________________________________________ Unit #: __________________
City: _________________________ State: __________ Zip: __________ County: ____________
Home phone: ______________________________ Cell phone: _____________________________
Email address: ____________________________________________________________________
Date of birth (Month/Day/Year):_____ /_____ /_____ Weight: __________ Height: ____________
Gender: o Male o Female Polo shirt size: o S o M o L o XL o XXL o XXXL
How did you hear about Honor Flight Chicago? __________________________________________
I am a veteran of: o WWII (12/41-12/46) o Korean War (6/50-1/55) o Vietnam War (11/55-5/75)
Dates you served in the military (Month/Year to Month/Year): _____ /_____ to _____ /_____
Branch of service:
o Army o Air Corps/Force o Navy o Other _____________
o Marines o Coast Guard o Merchant Marines
Rank: ________________________________ Service number: ____________________________
Hometown
(From which city and state did you enter the service)? __________________________________________
Country(ies) where you served: _______________________________________________________
________________________________________________________________________________
Activity during the war: _____________________________________________________________
________________________________________________________________________________
Honor Flight Chicago
Veteran Application
Honor Flight Chicago recognizes America’s senior war veterans for their bravery, determination,
and patriotism with an all-expense-paid, one-of-a-kind journey to Washington, D.C., for a day of honor,
thanks, and inspiration. Priority is given to WWII and Korean War veterans: our most senior veterans.
Vietnam veteran applications are prioritized based on the date they are received. To be eligible, a veteran
needs to have served on active duty during a war era.
Veterans will receive a longer application to update their medical information when we anticipate flying them
within a calendar year. For questions, contact us at 773-227-8387 or go online to honorightchicago.org.
REFERRED BY _______________________________________________________________ PHONE _______________________________
(As it appears on your state ID for airline travel) (If applicable)
HFC USE ONLY: Last name _____________________________________________ Date received _________________
Please complete and submit
all three pages of this form
with required signature(s)
as soon as possible to:
Honor Flight Chicago
Attn: Veteran Application
9701 W. Higgins Rd., Suite 310
Rosemont, IL 60018-4703
Email:
applications@honorflightchicago.org
**Fax: 773-289-0909
**Conrm all 3 pages have sent.
Page 2 of 3
Honor Flight Chicago
honorightchicago.org
Veteran Application - 2020
12/1
9
Please list your current work experience (if retired, please list your most recent work experience):
Organization: __________________________ Title: ________________ Dates (from/to): _________
Primary responsibilities/accomplishments: ______________________________________________
________________________________________________________________________________
CONTACT INFORMATION
Primary emergency contact (someone available the day you travel):
Name: ___________________________________________ Relationship: _____________________
Address: _______________________________ City: ______________ State: ______ Zip: _______
Phone:
Day __________________________________ Evening ______________ Cell ________________________
Email: ___________________________________________________________________________
Non-Spouse alternate contact (son, daughter, grandchild, personal friend):
Name: ___________________________________________ Relationship: _____________________
Address: _______________________________ City: ______________ State: ______ Zip: _______
Phone: Day __________________________________ Evening ______________ Cell ________________________
Email: ___________________________________________________________________________
BUDDY & GUARDIAN INFORMATION
If you and a fellow veteran from your service era would like to travel together, please ask him/her to complete
a Veteran Application. In addition, please include your buddy’s name and number below so that we may try to
pair you together on the same flight.
Buddy’s name: ____________________________________ Buddy’s phone: ____________________
Buddy’s email (if applicable): ___________________________________________________________
Honor Flight Chicago provides trained Guardians to ensure you have a safe and memorable experience. If
you would prefer to have a family member (child, grandchild, niece, nephew, etc., aged 18 - 66) be
considered as your Guardian, provide their name below and have them complete a Guardian Application at
honorflightchicago.org. Guardians must attend a three hour training class and pay a fee to cover a portion of
the day's cost. Completion of the Guardian Application combined with the information below ensures that
your request is considered, however selection is not guaranteed. Medically necessary family Guardians are
seated first, then all other requests are considered for any available open seats. Your spouse is NOT eligible.
Requested guardian name: ______________________________ Phone: ____________________
Requested guardian email: ______________________________ Relationship: _______________
Additional comments or concerns: ______________________________________________________
__________________________________________________________________________________
Page 3 of 3
Honor Flight Chicago
honorightchicago.org
Veteran Application - 2020
12/1
9
YOUR MEDICAL INFORMATION
The following medical information is necessary for Honor Flight Chicago’s volunteer, medical and
administrative staff to ensure that you have a safe and memorable day.
1. Please check any mobility equipment used: o Cane o Walker o Wheelchair o Scooter
2. Can you climb 5 stairs using handrails with minimal assistance? o Yes o No
If not, we can provide a wheelchair lift to get you on and off the bus.
3. How far can you walk without assistance?
o None o 0-10 steps o 25 feet o One block or more
4. Do you have a history of seizures? o Yes o No Please describe: _______________________________
(i.e. grand mal, petit mal, other)
When was your last seizure? ___________________
5. Do you have any breathing problems? o Yes o No
If yes, please describe: _____________________________________________________________________
6. Do you use oxygen at any time? o Yes o No
7. Do you smoke? o Yes o No
8. Do you have diabetes? o Yes o No If yes, injected or oral? o Injected o Oral
Do you carry glucose with you? o Yes o No
Other health problems: _________________________________________________________________
Allergies: ____________________________________________________________________________
MEDICATIONS (name and how often taken - If necessary, please attach additional sheets):
Medication Taken how often? Medication Taken how often?
_____________________________ ________________ _______________________________ ______________
_____________________________ ________________ _______________________________ ______________
_____________________________ ________________ _______________________________ ______________
_____________________________ ________________ _______________________________ ______________
_____________________________ ________________ _______________________________ ______________
The Veteran acknowledges and agrees that the information on this application is correct.
Veteran’s signature is required.
Please sign and print your name below.
Veteran’s signature: ________________________________________________________________
Print name: ______________________________________________ Date: _________________
If you are completing this application for your veteran, please print your name, relationship to the veteran
and provide a phone number for us to contact you.
Please sign your name: _____________________________________________________________
Please print your name: _____________________________________________________________
Relationship: __________________________ Phone number: ____________________________
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Honor Flight Chicago Veteran Application Honor Flight Chicago

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Completed 21 June 2021

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