Veteran Application

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Your Details

Title

First Name*

Middle Name

Last Name*

Suffix

Email*

Phone number

Ext.

Work Mobile Home

Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country*

Additional Information For Your Application(s)

1 X Veteran Application for Southwest FL Honor Flight

Badge Nickname:

Required

Characters Remaining: 500

ZIP:

Required

Characters Remaining: 500

Primary Phone:

Required

Characters Remaining: 500

Birthdate:

Required

T-Shirt Size:

Required

Weight (must have for airline manifest):

Required

Characters Remaining: 500

Height: (Ft, Inch)

Required

Characters Remaining: 500

SERVICE HISTORY

Hometown:

Required

Characters Remaining: 500

Military Branch:

Required

Rank:

Required

Characters Remaining: 500

Service Dates:

From

Required

Career Field/Units Assigned/Locations INCLUDED any special condemnations:

Required

Characters Remaining: 500

Special condemnations: (please list any military honors/models you received)

Required

Characters Remaining: 500

Please submit a copy of your DD214 documents or a copy of your VA card and your Driver's license or state-issued ID card.

Veteran's Name:

Required

Characters Remaining: 500

VETERAN CONTACTS

Spouse

Spouse Name:

Required

Characters Remaining: 500

Spouse Street Address:

Required

Characters Remaining: 500

Spouse City:

Required

Characters Remaining: 500

Spouse State:

Required

Characters Remaining: 500

Spouse ZIP:

Required

Characters Remaining: 500

Spouse Primary Phone:

Required

Characters Remaining: 500

Spouse Cell Phone:

Required

Characters Remaining: 500

Spouse Email Address:

Required

Characters Remaining: 500

In case of Emergency, call(someone available the day you travel and not traveling with you)

Emergency Contact Name:

Required

Characters Remaining: 500

Emergency Contact Relationship:

Required

Characters Remaining: 500

Emergency Contact Street Address:

Required

Characters Remaining: 500

Emergency Contact City:

Required

Characters Remaining: 500

Emergency Contact State:

Required

Characters Remaining: 500

Emergency Contact ZIP:

Required

Characters Remaining: 500

Emergency Contact Primary Phone:

Required

Characters Remaining: 500

Emergency Contact Cell Phone:

Required

Characters Remaining: 500

Emergency Contact Email Address:

Required

Characters Remaining: 500

If you would like to have a specific relative or friend serve as your Guardian Escort, please provide his/her name and phone number. (Must be the age of 18 and able to handle the rigors of the day). He/she must submit a Guardian application and pay guardian fees. (available at www.swflhonorflight.org).

Requested Guardian Name:

Required

Characters Remaining: 500

Guardian Phone number:

Required

Characters Remaining: 500

Relationship of Guardian:

Required

Characters Remaining: 500

Guardian Email Address:

Required

Characters Remaining: 500

If you wish to experience your trip to Washington, D.C. with a Veteran buddy, please list his/her name and phone number. Your Buddy must also submit an application and we suggest submitting your application together.

Veteran Buddy's Name:

Required

Characters Remaining: 500

VETERAN MEDICAL INFORMATION

Please list any chronic illnesses (i.e., cancer, Parkinson's, heart issues, etc.) and the date of diagnosis: (Information is for scheduling purposes and does not exclude you from a trip.)

Required

Characters Remaining: 500

Do you normally use mobility assistance?

Note: We provide a wheelchair for every Veteran and will not take a personal wheelchair, walker, or Motorized Unit on the trip. You may bring a personal cane if desired.

Required

Are you able to go up/down 6 steps to get on/off the bus with help?

Required

Do you have a history of Epilepsy or seizures?

Optional

If Yes, please describe:(i.e., grand mal, petit mal, other)

Optional

Characters Remaining: 500

Have you had a stroke?

Required

If Yes, when?

Required

Are you short of breath after exerting yourself?

Required

Do you carry an inhaler?

Required

Do you use Oxygen at any time?

Required

Do you have kidney problems?

Required

Are you on dialysis?

Required

Do you have a urostomy or colostomy bag?

Note: If Yes, please make sure the bag is vented prior to flight. If you do not know if your bag is vented, you must discuss the issue wit your private physician.

Required

Are you Diabetic?

Required

Does your medication require refrigeration?

Required

Do you carry glucose with you?

Note: If you are insulin dependent, your physician must write a prescription for insulin to be used during the trip.

Required

Do you have a pacemaker/internal defibrillator?

Required

Please list any food or drug allergies:

Required

Characters Remaining: 500

Please list any food restrictions:

Required

Characters Remaining: 500

Please list any other area(s) of concern:

Required

Characters Remaining: 500

Are you a Snowbird?

Optional

Snowbird Address:

Optional

Characters Remaining: 500

How did you find out about Honor Flight?

Your application will be entered into our database based on the date received. Priority goes to any terminally ill Veteran, then WWII Vets (service 1948 and earlier), then Korean War Vets (service 1950-1955), then Vietnam (service 1955-1975), and then any service 1976 to the present.

Required

Characters Remaining: 500

Read and Sign Waiver

Please Review Carefully and Sign

The undersigned acknowledges and agrees that:

1. I state that the information provided in this application reflects a true and accurate summary of my

personal status to the best of my ability.

2. I also state that I understand that personal medical insurance is my responsibility and I understand that

Southwest Florida Honor Flight does not provide medical care for me. I understand that I accept all

risks associated with travel and other Southwest Florida Honor Flight activities and will not hold

Southwest Florida Honor Flight staff, Honor Flight volunteers or vendors encountered during related

activities responsible for any injuries or illness incurred by me while participating in the Southwest

Florida Honor Flight program.

3. As photographic, video, and audio equipment are frequently used to memorialize and 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 the

videographer/photographer and Southwest Florida Honor Flight from all claims and liability relating to

said images. 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 of compensation or ownership thereto.

4. You must attend a MANDATORY orientation (generally the Saturday prior to the flight). After

submitting an application, you must be approved by SWFL Honor Flight leadership to participate. You

will be contacted by a representative so it is important that the above information is legible and

accurate.

I accept the terms of the waiver.

Type your name to sign:*

Birth Date:*

Month

Day

Year

IP: 44.200.168.16
Mar. 30, 2023

By clicking I agree to the terms.

Your Details

Additional Information For Your Application(s)

1 X Veteran Application for Southwest FL Honor Flight

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