Fillable Honor Flight Chicago Veteran Combined Application and Medical

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Honor Flight Chicago Veteran Combined Application and Medical

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Page 1 of 7
Honor Flight Chicago
honorightchicago.org
Veteran Combo 2020
12/19
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 Force o Navy o Other
___________________
o Marines o Coast Guard o Merchant Marines
Rank: ________________________________ Service number (optional): ____________________
Hometown (From which city and state did you enter the service)? __________________________________________
Country(ies) where you served: _______________________________________________________
________________________________________________________________________________
Activity during the war:
_____________________________________________________________
________________________________________________________________________________
Honor Flight Chicago
Veteran Combined
Application and Medical Form 2020
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.
You have been invited to complete this seven-page application because we anticipate flying you in 2020.
As soon as the completed form is received by Honor Flight Chicago and it is confirmed that all pages are
complete, we will send it to our Medical Team for review. When approved, you will be placed in the queue
for one of our upcoming flights. Priority is given to our most senior veterans, our WWII and Korean War
veterans. All Honor Flight Chicago trips depart and return from Chicago Midway International Airport. For
further information, please contact us at 773-227-8387 or go online to honorflightchicago.org.
REFERRED BY _______________________________________________________________ PHONE _______________________________
(As written on your state ID. NOTE: Real ID required after 10/1/20)
(If applicable)
HFC USE ONLY: Last name _____________________________________________ Date received _________________
Please complete and submit
all seven pages of this form
with required signature(s)
as soon as possible to:
Honor Flight Chicago
Attn: Veteran Combo App 2020
9701 W. Higgins Rd., Suite 310
Rosemont, IL 60018-4703
Scan & Email:
applications@honorflightchicago.org
**Fax to 773-289-0909
**Conrm all 7 pages have sent
Page 2 of 7
Honor Flight Chicago
honorightchicago.org
Veteran Combo 2020
12/19
Please list your current work experience (if retired, please list your most recent work experience):
Organization: __________________________ Title: ________________ Dates (from/to): _________
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 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 can try to pair you together on
the same flight. Since we invite our veterans to fly based on date order of applications received, we may not
be able to accommodate your request. We will discuss this with you when we call to invite you on your flight.
Buddy name: _________________________________________ Buddy Phone: ______________
Buddy 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 7
Honor Flight Chicago
honorightchicago.org
Veteran Combo 2020
12/19
YOUR MEDICAL INFORMATION
1. Place of residence:
o Private home o Private condo/apartment o Independent living
o Assisted living o Nursing home o Retirement Community
Who do you live with? Name: _____________________________ Relationship: _____________
Name of Residence Facility/Community: _____________________________________________
2. Do you have a personal care attendant? o Yes 8-12 hours ___ 24 hours ___
2-4 times per week ___
o No
3. Do you attend adult day care? o Yes How many days per week? __________
o No
4. Please check all that apply: o Cane o Walker o Crutches o Wheelchair
o Scooter o Prosthetics/braces o None of the above
5. Can you climb five stairs using handrails with minimal assistance o Yes o No
If not, we can provide a wheelchair lift into and out of the bus.
6. How far can you walk without assistance?
o None o 0-10 steps o 25 feet o One block or more
7a
. Have you suffered an injury from a fall in the past six months? o Yes o No
If yes, please specify: ____________________________________________________________
7b. Have you been hospitalized or had surgery in the past six months?
(If yes, please list below) o Yes o No
Reason for Surgery or Hospitalization Date
8. Do you have diabetes? o Yes o No
If yes, how do you control it? o Insulin o Pill o Diet controlled
If controlled with Insulin injections, your private physician must write a prescription for Insulin
to be used on flight day. Insulin prescription MUST be turned in with your application.
You are REQUIRED to bring your Insulin or oral medication, injection supplies, and glucometer
on the trip. If you arrive at the airport without these, you may not be allowed on the trip.
9. Do you have a pacemaker? o Yes o No
Do you have a defibrillator o Yes o No
Do you have a history of heart problems? o Yes o No If yes, please specify: ___________
_____________________________________________________________________________
Page 4 of 7
Honor Flight Chicago
honorightchicago.org
Veteran Combo 20
/19
10. History of COPD or asthma?
o Yes o No If yes, please describe: ________________________________________
11. Are you prescribed oxygen by your doctor?
o Yes o No
If yes, how many liters? __________________________________________
o 24 hours o As needed o With sleep apnea mask
o Night time only (not related to sleep apnea)
If yes, your private physician must write a prescription for oxygen to be used during the fligh
and/or day. Oxygen will be provided by Honor Fight Chicago. Oxygen prescription MUST be
turned in with your application.
12. Do you need nebulizer treatments or use an inhaler?
o Yes o No If yes, how often? ____________________________________________
13. Any history of heat exhaustion or difficulty breathing in the heat o Yes o No
14. Do you have a history of high blood pressure or on medication for it? o Yes o No
15. Do you have any history of visual impairment (other than glasses)?
o Yes o No If yes, please describe: ________________________________________
16. History of neurological problems (i.e., stroke, Parkinson’s disease)?
o Yes o No If yes, please describe: ________________________________________
17. History of seizures or taking seizure medications? o Yes o No
If yes, please list type of seizure: (i.e., grand mal, petit mal, other) _________________________
When was your last seizure? ______________________________________________________
18. Do you have problems with motion sickness? o Yes o No
19. History of dementia or Alzheimer’s OR are you on prescription medications for memory?
o Yes o No
20. History of anxiety or PTSD-related symptoms? o Yes oNo
21. Do you use incontinence pads?
Bladder: o Yes o No Bowel: o Yes o No
How often do you need to change your pads/depends? _________________
Are you able to change: oIndependently oWith minimal assistance oWith stand-by assistance
Does someone provide this care for you? o Yes o No
22. Do you have a foley, urostomy, or colostomy bag? o Yes o No
23. Are you currently undergoing dialysis? o Yes o No
24. Do you smoke? o Yes o No
Page 5 of 7
Honor Flight Chicago
honorightchicago.org
Veteran Combo 20
/19
25. Please list any allergies you have______________________________________________
Any bee sting reaction? o Yes o No
Do you carry an epinephrine pen with you? o Yes o No
If yes, please bring your epinephrine pen with you on the trip. Initial here: _______
26. Other medical or health concerns not previously disclosed:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
MEDICATIONS (List or attach a separate sheet)
Honor Flight Chicago medical volunteers are not authorized to dispense medications
Physician’s name: ________________________________________________________________
Physician’s phone number: _____________________________ Fax number: ______________________
Date of last exam: ____________________________________
Other physician’s name: ___________________________________________________________
Physician’s phone number: _____________________________ Fax number: ______________________
Date of last exam: ____________________________________
Page 6 of 7
Honor Flight Chicago
honorflightchicago.or
Veteran Combo 2020
12/19
MEDICAL RELEASE
The information I have provided is complete and accurate. I understand that Honor Flight Chicago medical
volunteers will review my health history and may speak with my healthcare provider(s) to clarify any medical
concerns. Honor Flight Chicago must medically approve all participants to fl . I agree to notify Honor Flight
Chicago immediately should my medical condition change prior to the trip. If any of this information is falsifie
or pertinent medical information is omitted, or if my medical conditions change or are determined by Honor
Flight Chicago to be unacceptable to participate, I understand I may be disqualified from participating in an
Honor Flight at the sole discretion of Honor Flight Chicago. I understand that medical insurance and medical
costs that may be incurred pursuant to participation are my responsibility and that Honor Flight Chicago does
not provide medical care. I understand that I accept all risks associated with travel and other Honor Flight
Chicago activities, and that I have executed a Release, Covenant Not to Sue and Indemnity agreement in
favor of Honor Flight Chicago while participating in the program. I hereby give consent and permission
to any of my medical providers or emergency medical providers to discuss and release my health
and treatment information for treatment purposes I may require during my participation in the Honor
Flight Chicago program and my signature on this page shall be sufcient evidence of my consent.
My signature authorizes you to call my physician or any other personnel familiar with my care to discuss my
medical history. Please note that a facsimile signature will also be accepted as an original signature.
Veteran signature required: __________________________________________________________
Please print your name: _____________________________ Date form completed: ____________
If the Veteran was assisted in completion of this form, please sign here and print your name, relationship and
phone number:
Please sign your name: _____________________________________________________________
Please print your name: _____________________________________________________________
Relationship: __________________________ Phone number: ____________________________
Sign Here
HONOR FLIGHT CHICAGO RELEASE, COVENANT NOT TO SUE AND INDEMNITY AGREEMENT
(PAGE 1 OF 2)
I, __________________________________, am about to voluntarily participate as a participant or a
volunteer in various Activities, which may include but are not limited to either being escorted or escorting
individuals with disabilities, crowd control and interaction, taking commercial aircraft flights, physical
activities, driving to activities, preparing documentation and other activities as a participant or as a
volunteer with or on behalf of and at the direction of Honor Flight Chicago Corp, an Illinois not for profit
corporation, which includes any office , director, employee, volunteer or agent thereof (“Honor Flight
Chicago”). In consideration of and as a condition of Honor Flight Chicago permitting me to participate in
these Activities, the sufficiency and receipt which I hereby acknowledge, knowingly, on behalf of myself, my
heirs, administrators, successors, executors and assigns, hereby covenant and agree:
(i) I am aware that there are inherent risks in the Activities and that I am freely assuming all risks of any
nature and damages related to such Activities including those related to my own health issues and
fully release Honor Flight Chicago from all such liability relating to same.
Page 7 of 7
Honor Flight Chicago
honorightchicago.org
Veteran Combo 2020
12/19
Sign Here
HONOR FLIGHT CHICAGO RELEASE, COVENANT NOT TO SUE AND INDEMNITY AGREEMENT
(PAGE 2 OF 2)
(ii) To never institute, prosecute, or in any way aid in the institution or prosecution of any demand, claim or
suit of any nature against Honor Flight Chicago for any destruction, loss, damage or injury (including
death) to my person or property or that of others which may occur from any cause whatsoever as
a result of my participation now or in the future, known or unknown, foreseen or unforeseen in the
activities of Honor Flight Chicago, and agree to discharge, defend, indemnify and hold Honor Flight
Chicago harmless from all such claims, damages, injuries or costs which may be incurred or which
arise as a result thereof.
(iii) I hereby forever, waive, release and discharge any demands or claims or suits of any nature, known
or unknown irrespective when such occur now or in the future, known or unknown, foreseen or
unforeseen including but not limited to any destruction, loss, damage or injury (including death)
to my person or property or that of others arising from my participation in the Activities, against
Honor Flight Chicago, and agree to defend, indemnify and hold Honor Flight Chicago harmless
from all such claims, damages, injuries or costs which may be incurred or which arise as a
result thereof.
(iv) Notwithstanding any provisions to the contrary in the event of any litigation or arbitration resulting
from my activities of any nature with Honor Flight Chicago that I agree that venue and jurisdiction
is limited to that of the Courts in Cook County Illinois and or the United States District Court for the
Northern District of Illinois Eastern Division and that Illinois law shall govern.
I hereby, authorize Honor Flight Chicago the continued right in perpetuity to photograph, film or video my
Activities and to publish same and or use such in the legitimate promotion of Honor Flight Chicago as they
deem t and as such I waive any right to approve same in advance.
I ACKNOWLEDGE THAT
I HAVE READ THIS AGREEMENT AND UNDERSTAND ITS TERMS AND
CONDITIONS AND VOLUNTARILY AGREE TO THE TERMS.
Veteran signature required: _________________________________________________________________________
Please print your name: _________________________________________ Date form completed: ________________
If the Veteran was assisted in completion of this form, please sign here and print your name, relationship and phone
number:
Please sign your name:
____________________________________________________________________________
Please print your name: ____________________________________________________________________________
Relationship: ____________________________________ Phone number: _________________________________
Mail, fax, or scan & email all seven pages to:
Honor Flight Chicago
Attn: Veteran Combo App 2020
9701 W. Higgins Rd., Suite 310
Rosemont, IL 60018-4703
Fax: 773-289-0909
Email: applications@honorightchicago.org
Please print this form out in its entirety and mail, fax or scan & email
the completed document to Honor Flight Chicago.
If completing the form electronically, please save the document to
your computer rst before printing. Electronically completed forms
will not print properly if not saved rst.
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Honor Flight Chicago Veteran Combined Application and Medical

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Completed 18 February 2021

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