HONOR FLIGHT NETWORK
CENTRAL PRAIRIE HONOR FLIGHT
LOCAL INFORMATION AVAILABLE THROUGH "CENTRAL PRAIRIE RC&D"
1817 16th Street; Great Bend, KS 67530; [email protected]
FOR HONOR FLIGHT USE ONLY: Last Name:______________ Date Received______/______/______
Veteran Application
Honor Flight recognizes American veterans for your sacrifices and achievements by flying you to Washington, DC to see YOUR memorial at no cost. (for which we are currently accepting application only) is given to WWII and terminally ill veterans from all wars. In the future, Honor Flight will be expanded to include Korean and Viet Nam Veterans. In order for Honor Flight to achieve this goal, guardians fly with the veterans on every flight providing assistance and helping veterans have a safe, memorable and rewarding experience. For what you and your comrades have given to us, please consider this a small token of appreciation from all of us at Honor Flight. For further information, please contact us at (620) 792-6224 or visit us at www.honorflight.org
YOUR NAME:____________________________________________________________ NICK NAME:______________________________________________
(As it appears on your ID for airline travel) (If Applicable)
ADDRESS:____________________________________________________________________________________________________________________________
CITY:___________________________________________________________________ STATE:______________________________ ZIP:___________________
PHONE: Day:_______________________________________ Evening:________________________________ Cell Phone:___________________________
E-MAIL ADDRESS:____________________________________________________________WEIGHT:___________________________ AGE: ____________
HOW DID YOU HEAR ABOUT HONOR FLIGHT?________________________________________________________________________________________
______________________________________________________________________________________. TEE SHIRT SIZE: (S,M,L,XL,XXL,XXXL)_________
| ALTERNATE CONTACT:
(Son, daughter, etc.) NAME:____________________________________________________________ PHONE:______________________ E-MAIL:__________________________RELATIONSHIP:________________________ |
| Do you have another
veteran and/or guardian you wish to travel with? ___________________________________ Please List Name |
EMERGENCY CONTACT INFORMATION: (SOMEONE AVAILABLE THE DAY YOU TRAVEL)
Name:_________________________________________________________________ Relationship:________________________________
Address:_____________________________________________________________________________________________________________
Phone: Day:_______________________________________Evening:_________________________Mobile:__________________________
SERVICE HISTORY: BRANCH OF SERVICE:_________________________ RANK:_________________
HOME TOWN: (From which city and state did you enter the service?)_______________________________________________
ACTIVITY DURING WWII:________________________________________________________________________________.
MEDICAL: INFORMATION PROVIDED WILL NOT DISQUALIFY YOU. IT PERMITS US TO ASSESS THE SUPPORT WE NEED DURING THE TRIP. INFO IS FOR HONOR FLIGHT AND MEDICAL PERSONNEL ONLY.
Do you use mobility equipment? (Circle One) YES NO If YES, please circle device: Cane Walker Wheelchair Scooter
MEDICATIONS
MEDICATION TAKEN HOW OFTEN MEDICATION TAKEN HOW OFTEN
____________________ ________________________ / ___________________ _________________________
____________________ ________________________ / ___________________ _________________________
____________________ ________________________ / ___________________ _________________________
____________________ ________________________ / ___________________ _________________________
Do you have any drug allergies?____________________________________________________________________________
Do you have a history of seizure? (Circle One) yes no If yes, please describe what type: _____________________________
(grand mal, petit mal, other)
When was your last seizure?_____________________________. If within the past 5 years. STRONGLY advise you to discuss trip with your private physician!
Please complete back of page
In the following questionnaire please circle the correct response)
Do you have problems with motion sickness? YES NO
If YES is it controlled with medications? YES NO
If motion sickness is not controlled with medications, it is STRONGLY advised you discuss the trip with your physician!
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Do you have any breathing problems? YES NO
If YES please describe._________________________________________________________________________________
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Do you have a home nebulizer machine? YES NO
If YES, you are STRONGLY encouraged to discuss the trip with your physician concerning the use of portable hand-held nebulizers !
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Do you use oxygen at any time? YES NO
If YES, you will need your private physician to write a prescription for oxygen to be used during the flight and during the tour. Oxygen will be provided. The prescription should be turned in with the application.
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Do you have/use a wheel chair? YES NO
Can you walk without breaks? YES NO Please check how far. 500 feet � 1500 feet � 3000 feet �
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Do you have a history of open head injuries, sinus problems, or ear problems? YES NO
If YES, have you flown since the open head injury, sinus or ear problems occurred? YES NO
If YES, did you have any problems? YES NO
If YES, it is STRONGLY advised you discuss the trip with your private physician. If you have NEVER flown since the open head injury head injury, sinus or ear problems, again we STRONGLY advise you to discuss the trip with your private physician.
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Do you have a urostomy or colostomy bag? YES NO
If YES, please make sure the bag is vented prior to flight. If you do not know if your bag is vented, it is STRONGLY advised that you discuss this issue with your private physician.
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Additional Comments or Concerns: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
PLEASE REVIEW CAREFULLY AND SIGN
The undersigned acknowledges and agrees that:
(1) As photographic and video equipment are frequently used to memorialize and document Honor Flights trips and events, his/her image may appear in a public forum, such as the media or a website, to acknowledge, promote or advance the work of the Honor Flights program. I hereby release the photographer and Honor Flights from all claims and liability relating to said photographs. I hereby give permission for my images captured during Honor Flights activities through video, photo, or other media, to be used solely for the purposes of Honor Flight promotional material and publications, and wave any rights or compensation or ownership hereto.
(2) I further state that medical insurance is the responsibility of the veteran and I understand that Honor Flight does 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.
SIGNED:______________________________________________________
DATE:________/__________/__________ (e-mail applicants will be required to sign prior to actual flight date)
Send this application to:
Central Prairie Honor Flight
C/O Central Prairie RC&D Council
1817 16th Street
Great Bend, Kansas 67530
Or fax your Veterans Application to: 620-792-4875 or contact us by Phone at: 620-792-6224
Donations are welcome * A letter acknowledging this donation will be mailed to the designated donor
All programs and services of Central Prairie RC&D and their "Honor Flight" program are offered on a non-discriminatory
basis without regard to race, color, national origin, age, marital or family status, disability, or political beliefs.