Veteran Application - Honor Flight of Dubuque and the Tri-States

Honor Flight recognizes American Veterans for your sacrifices and achievements by flying you to Washington DC to see YOUR memorial at no cost. We are currently accepting applications for Veterans from all wars with top priority given to terminally ill veterans. Dates of service, age and application date will determine the order in which Veterans are chosen for each flight. In order for Honor Flight to achieve this goal, guardians fly with the veterans on every flight providing assistance and helping all veterans have a safe and memorable experience. For what you and your fellow Veterans have given to us, please consider this flight a small token of appreciation from all of us at Honor Flight. For further information, please call 563-690-0815 or visit us at www.honorflightdbq.org.

PLEASE NOTE:

Your spouse CANNOT be your guardian

Your Information

Do you have a REAL ID or an active passport?YesNo

PLEASE LIST YOUR FULL FIRST, MIDDLE, AND LAST NAME AS IT APPEARS ON YOUR DRIVER’S LICENSE OR GOVERNMENT ID.

First Name *Full First Name (no nicknames or shortened names)

Middle Name *Full Middle Name

Last Name *Full Last Name

Street Address *

Apartment, suite, etc

City *

State *

ZIP Code *

Best Contact Phone Number *

Email Address

GenderMaleFemale

Date of Birth

Age

Weight

Shirt Size

Service History:

Branch

War/Conflict

What years did you serve?

Name of Guardian you are requesting to travel withThere are NO GUARANTEES they will be selected to be your guardian.

Emergency Contact

(person to contact the day you travel)

Name

Relationship

Best Contact Phone Number *

Email Address

Alternate Contact

This person should not be the same person as your Emergency Contact

Name

Best Contact Phone Number

Email Address

Medical Information

The information provided will NOT disqualify you. It permits us to assess the support needed during the trip. Information is for Honor Flight medical personnel ONLY.

Can you walk the length of a football field without assistance?YesNo

Do you have breathing problems?YesNo

If yes, do you use oxygen?

If yes you will need a prescription from your physician for oxygen to be used on the trip. The oxygen will be provided. The prescription should be turned in with this application.

Do you have allergies, history of seizures, motion sickness, home nebulizer machine, history of open head injuries, sinus or ear problems, urostomy or colostomy bag?YesNo

Print legibly a list of your medications and dosage on a 3 x 5 card or small piece of paper to carry with you on the day of your flight.

Additional comments or concerns:

SignedBy typing your name, you acknowledge the above.

Date *