Fillable Honor Flight of West Central Florida, Inc. (Honor

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Honor Flight of West Central Florida, Inc. (Honor

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CONFIDENTIAL
FOR HONOR FLIGHT OF WEST CENTRAL FLORIDA USE ONLY Last Name: _______________________Date Rec’d: ____/____/_____
Honor Flight® of West Central Florida, Inc. is an Official Hub of the Honor Flight® Network
727-498-6079 www.honorflightwcf.org
rev 3/8/2020 baf
Honor Flight® of West Central Florida, Inc. (“Honor Flight”) recognizes America’s Veterans for their sacrifice and service by
flying you FREE OF CHARGE to Washington, D.C. to visit and reflect at the memorial dedicated in your honor. This is a one
day trip to Washington flying from St.Pete/Clearwater Airport in Clearwater, FL. Top priority is given to WWII and
terminally ill Veterans. Once these groups have flown, Honor Flight is committed to fly Veterans from the Korean, Vietnam
and Gulf wars. For what you have given to us, please consider this a small token of appreciation from all of us at Honor
Flight. For more information, please contact us at info@honorflightwcf.org, call us at 727-498-6079 or visit our website at
www.honorflightwcf.org.
YOUR NAME: ______________________________________________________________ SEX: M or F
First Middle Last
(Name must match photo ID with D.O.B. for airline travel – Driver’s License, passport, VA ID card, etc.)
ADDRESS:
CITY: COUNTY: STATE: ZIP:
PHONE:
CELL PHONE:
E-MAIL: Date of Birth*
*REQUIRED (MM/DD/YYYY)
YOUR SHIRT SIZE:
Small
Medium Large Extra Large (XL) XXL
XXXL
EMERGENCY CONTACT INFORMATION (SPOUSE OR OTHER – NOT GUARDIAN ON FLIGHT):
NAME: RELATIONSHIP:
PHONE: CELL PHONE:
EMAIL:
ALTERNATE EMERGENCY CONTACT INFORMATION
(NOT SPOUSE OR GUARDIAN ON FLIGHT):
NAME: RELATIONSHIP:
PHONE: CELL PHONE:
EMAIL:
SERVICE HISTORY
I am a: WWII Veteran Korean War Veteran
Vietnam War Veteran Other: _____________
BRANCH OF SERVICE: DATES SERVED:
PLACES WHERE YOU SERVED: ____________________________________________________________________
ACTIVITY DURING YOUR SERVICE:
VETERAN APPLICATION
CONFIDENTIAL
FOR HONOR FLIGHT OF WEST CENTRAL FLORIDA USE ONLY
Honor Flight® of West Central Florida, Inc. is an Official Hub of the Honor Flight® Network
727-498-6079 www.honorflightwcf.org
rev 3/8/2020 baf
GENERAL INFORMATION
May we contact you in the future about Honor Flight activities/events? YES NO
Have you ever been on an Honor Flight tour before? YES NO
BUDDY 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 may try to pair you together on the
same flight.
Buddy’s Name: __________________________________________ Phone: ______________________________
GUARDIAN INFORMATION
To help ensure a safe and memorable experience, Honor Flight will assign you your own personal “Guardian” for
the day. Your trained “Guardian” will provide excellent care and is responsible for being by your side
throughout the trip.
If there is someone specific (ages 18-70) you would like to be considered to act as your Guardian, please list that
person’s contact information below. The Guardian Application found at www.honorflightwcf.org must be
completed by your potential Guardian and submitted with your Veteran Application to assure consideration,
however selection is NOT guaranteed. Your spouse/significant other is NOT eligible to be your guardian.
Requested Guardian Name: ___________________________________ Phone: ___________________________
Relationship to you: ___________________________________________________________________________
Additional Comments or Concerns: _______________________________________________________________
____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
CONFIDENTIAL
FOR HONOR FLIGHT OF WEST CENTRAL FLORIDA USE ONLY
Honor Flight® of West Central Florida, Inc. is an Official Hub of the Honor Flight® Network
727-498-6079 www.honorflightwcf.org
rev 3/8/2020 baf
MEDICAL INFORMATION
The purpose of this form is to provide Honor Flight and/or emergency medical technicians information about the
participants should an emergency arise.
Name __________________________________________________________ Date of Birth: ____________________
Last First Middle
HFWCF will provide each Veteran a wheelchair if needed. We cannot take scooters. Do you use mobility equipment?
Please check any that you use: Cane _______ Walker _______ Wheelchair _______ Scooter _______
Please circle your ability to walk a half mile:
A. Easily, can walk more B. Can but slowly C. Would need some assistance
Are you able to climb 6 steps? Yes ___ No __
Have you fallen in the past 3 months? Yes ___ No ___
Have you fallen in the past 6 months? Yes ___ No __
Do you have any physical limitations that we should know about?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Do you have any concerns about traveling?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Veteran Medical Information:
1. Heart Attack: Yes ____ No ___ If yes, when __________________________________________________
By-pass Surgery: Yes ___ No __ If yes, when ______________________________________________
Pacemaker: Yes___ No ___ If yes, when __________________________________________________
2. Stroke: Yes ___ No ___ If yes, when _______________________________________________________
3. Do you use Oxygen: Yes ___ No ___ If yes, you will need a current script with flow rate
4.
Asthma: Do you use an inhaler: Yes ___ No __
5. Do you travel with a service animal? Yes ___ No __
If so, what service does this animal provide? _______________________________________________________
CONFIDENTIAL
FOR HONOR FLIGHT OF WEST CENTRAL FLORIDA USE ONLY
Honor Flight® of West Central Florida, Inc. is an Official Hub of the Honor Flight® Network
727-498-6079 www.honorflightwcf.org
rev 3/8/2020 baf
6. Are you diabetic? Yes ___ No __ If Yes, oral __________________ Injected ____________________
Does your medicine require refrigeration? Yes __ No ___
Do you carry glucose with you? Yes ___ No ___
7. Eye Problem: If yes, what kind: _____________________________________________________________
8.
Cancer: If yes, where ___________________________________ when ______________________________
9. Knee Surgery: Yes ___ No ___ If yes, when ___________________________________________
10. Back Problems: Yes __ No ___
11. Back Surgery: Yes ___ No ___ If yes, when ___________________________________________
12. CPAP: Yes ___ No ___ (continuous positive airway pressure machine)
13.
Bladder Problems: Yes ___ No ___ Do you use a catheter: Yes __ No ___
Are you incontinent: Yes ___ No ___ Do you wear Depends: Yes ___ No ___
14. Allergies: Yes ___ No ___ If yes, allergic to ______________________________________________________
15. Motion Sickness: Yes ___ No ___
16. Do you have a history of seizures: Yes ___ No ___ If yes, date of last seizure _______________
17. Do you have a history of open head injuries, sinus problems or ear problems: Yes ___ No ___
18. Do you have difficulty hearing: Yes ___ No ___ Hearing aids: Yes ___ No ___
Any health problems not listed above? ________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Prescription Medications:
Name of Medication
What for?
Name of Medication
What for?
1
4
2
5
3
6
Attach additional Medications to this form if needed.
✔
`
CONFIDENTIAL
FOR HONOR FLIGHT OF WEST CENTRAL FLORIDA USE ONLY
Honor Flight® of West Central Florida, Inc. is an Official Hub of the Honor Flight® Network
727-498-6079 www.honorflightwcf.org
rev 3/8/2020 baf
PLEASE REVIEW CAREFULLY AND SIGN
The undersigned acknowledges and agrees that:
1. As photographic and video equipment is frequently used to document Honor Flight trips and events, my
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 program. I hereby release any photographer/videographer and Honor Flight from all
claims and liability relating to said photographs/videos. I hereby give permission for my images captured during
Honor Flight activities through video, photo, or other media, to be used solely for the purposes of Honor Flight
promotional material and publications, and waive any rights or compensation or ownership thereto.
2. I understand that I may be featured on news reports or in photographs or video taken by media or news
outlets. I understand I have the right to consent/not consent to an interview with any news outlet. I understand
that Honor Flight will NOT provide my name, address, telephone number, or any other personal information to
any news or media outlet personnel.
3. I understand that Honor Flight will not provide my address, telephone number or any personal
information to anyone without my permission or without permission from the Board of Directors of Honor
Flight.
4. I understand that medical insurance is the responsibility of the individual passenger and I understand
that Honor Flight does NOT provide medical insurance or travel insurance. I understand that Honor Flight
personnel do NOT provide medical care. I understand that I accept all risks associated with travel and other
Honor Flight activities and will not hold Honor Flight responsible for any injuries incurred by me while
participating in the Honor Flight program.
SIGNATURE: DATE:
PRINT NAME: _____________________________________________
Please mail the completed application to:
Honor Flight of West Central Florida
P.O. Box 55661
St. Petersburg, FL 33732
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CONFIDENTIAL
FOR HONOR FLIGHT OF WEST CENTRAL FLORIDA USE ONLY Last Name: _______________________Date Rec’d: ____/____/_____
Honor Flight® of West Central Florida, Inc. is an Official Hub of the Honor Flight® Network
727-498-6079 www.honorflightwcf.org
rev 3/8/2020 baf
I agree to voluntarily participate in various activities including, but not limited to, a round-trip flight arranged by
Honor Flight® of West Central Florida, Inc. (“Honor Flight”). In consideration of this organization permitting me
to participate in these activities, I, for myself, my heirs, administrators, executors and assigns, hereby covenant
and agree that I will never institute, prosecute, or in any way aid in the institution or prosecution of any
demand, claim or suit against Honor Flight for any destruction, loss, damage or injury (including death) to my
person or property which may occur from any cause whatsoever as a result of my participation in the activities
of Honor Flight.
If I, my heirs, administrators, executors or assigns should demand, claim, sue or aid in any way in such a
demand, claim or suit, I agree, for myself, my heirs, administrators, executors, and assigns to indemnify Honor
Flight for all damages, expenses and costs it may incur as a result thereof.
I know, understand, and agree that I am freely assuming the risk of my personal injury, death or property
damage, loss or destruction that may result while participating in Honor Flight activities, including such injuries,
death, damage, loss or destruction as may be caused by the negligence of Honor Flight.
I understand and agree that I may be held liable for any damages or loss to Honor Flight which is caused by my
gross negligence, willful misconduct, dishonesty or fraud and for limited damages or loss to Honor Flight which is
caused by my negligence.
I further understand that Honor Flight organization includes the non-profit organization known as Honor Flight®
of West Central Florida, Inc. and any officer, director, agent and/or employee thereof.
Please mail the completed application to:
Honor Flight of West Central Florida
P.O. Box 55661
St. Petersburg, FL 33732
Veteran Covenant Not To Sue
and Indemnity Agreement
DATE
SIGNATURE
DATE OF BIRTH
PRINT NAME
SIGNATURE OF HONOR FLIGHT OFFICIAL
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Completed 17 November 2020

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