Online Guardian Application – new 8/15/17 Online Guardian Application – new 8/15/17 Please use this application to become a Guardian for Honor Flight Southern Nevada. Online Guardian ApplicationDate *Instructions Please read and initial the following statements prior to completing and submitting this online application. Guardians play a significant role in ensuring a safe and memorable experience for each Veteran. In order to be considered for the Guardian position, the applicant must: *Be between the ages of 18-70 years old. [Individuals under 18 and over 70 who apply are subject to further review.]I understand the above requirement and that I may be subject to further review: *Be physically fit and able to participate in a demanding day. Able to push 300lbs. in a wheelchair for 6 hours and be able to lift 70lbs., if necessary [Pushing a wheelchair, extensive walking, extreme weather]I acknowledge that I meet the above requirement: *Attend a MANDATORY Guardian Training session prior to the flight day. [Typically the training is two weeks prior to flight.]I acknowledge that I meet the above requirement: *Pay the $900 Guardian Fee. Fees must be paid to HFSN six (6) weeks prior to flight date. [Please note this fee covers the actual expenses for the Guardian.]I acknowledge that I am responsible for the cost of my trip.We often have more guardian applicants than we have seats available. Guardian selection will be confirmed. If you are not chosen for the flight, your name will go on the Guardian wait list. You will be contacted two months before a flight. Guardian InformationName *Provide your name as shown on driver's license or gov't issued IDAddress *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmail *Home Phone *Mobile Phone Date of Birth *Age Individuals under 18 and over 70 who apply, are subject to review and may be interviewed by Honor Flight Southern Nevada staff members.Gender *FemaleMaleNickname for Nametag T-Shirt Size *You will be provide a Honor Flight Southern Nevada T-shirt to wear on the trip.SmallMediumLargeX-LargeXX-LargeHave you been on an Honor Flight before? *YesNo Emergency Contact InformationEmergency Contact Name *Please provide who HFSN may contact in the event of an emergency.Emergency Contact Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryEmergency Contact Phone *Emergency Contact Email *Emergency Contact Relationship to Applicant: *Physician Name *Physician's Phone Number * Military HistoryAre you a veteran? YesNoService History If "yes", select one:Active DutyReserves/National GuardRetiredFormer Military (not retired)Years of Service Ranch and Branch Served Please provide rank and branch served:When/Where have you served: Please provide when you were in the service and where you were stationed:Are you requesting to fly with a specific veteran? YesNoIf you selected "yes" above, please provide veteran name and relationship: A completed Veteran Application must be submitted by the Veteran. Honor Flight Trip InformationHow did you hear about Honor Flight Southern Nevada? NewsFriend, RelativeWebsiteFundraising EventOutreach EventWhy are you volunteering for Honor Flight Southern Nevada? Please incidate your profession or if retired, please list your most recent work experience: Can you lift 70lbs? *As the flight day progresses, we have found that Veterans may need more assistance with ambulation and transfers.YesNoCan you push a wheelchair all day? *Some veterans may require to be in a wheelchair all day.YesNoCan you easily maneuver in tight spaces to assist Veteran if need? *(Airplane, Charter Bus, Bathrooms)YesNo Medical InformationTravel Concerns *Please document your medical history or conditions that would impact your travel.Do you smoke? *YesNoDo you suffer from allergies? *YesNoIf "yes" to allergies, please list type of allergies: Do you suffer from seizures? *YesNoSeizure Information If you selected "yes", please provide type of seizureProvide date of your last seizure: If suffered seizure within the last five (5) years, please discuss the trip with your primary physician.Do you have diabetes? *YesNoIf you selected "yes", how do you control it? PillInsulinDietDo you suffer from motion sickness? *YesNoIf yes, can it be controlled through medication? YesNoOption 3Do you currently have, or have you had a history of heart problems? *YesNoIf "yes", please explain: Are you claustrophobic? *YesNoAre you able to endure a 5-hour plane ride? *YesNoOther medical or health concerns not previously disclosed: PLEASE REVIEW CAREFULLY:PLEASE TYPE YOUR NAME IN THE BOX BELOW, ACKNOWLEDGING YOU AGREE TO THE STATEMENTS BELOW *I, hereby authorize HFSN and the HFN to investigate my qualifications for the purpose of evaluating whether I am qualified for the volunteer position for which I am applying. I understand that HFSN and the HFN may utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company’s choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for this volunteer position will not be processed further. *If under 18, parents/guardian must also sign and date below.Release, Waiver of Liability, Assumption of Risk, and Indemnity Agreement *PLEASE READ ALL PROVISIONS CAREFULLY BEFORE ACKNOWLEDGING: The undersigned acknowledges and agrees that: 1. As photographic and video equipment are frequently used to memorialize and document Honor Flight Southern Nevada (HFSN) and the Honor Flight Network (HFN) 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 HFSN and the HFN program. I hereby release the photographer and HFSN and the HFN from all claims and liability relating to said photographs, I hereby give permission for my images captured during HFSN and the HFN activities through video, photo, or other media, to be used solely for the purposes of HFSN and the HFN promotional material and publications, and waive any rights or compensation or ownership thereto. 2. I further state that medical insurance is the responsibility of the veteran, guardian, or volunteer, and I understand that HFSN, the HFN, and the provider of free private aircraft (“Flight Provider”) do NOT provide medical care. I understand that I accept all risks associated with travel and other HFSN and the HFN activities and will not hold HFSN, the HFN, or the Flight Provider responsible for any injuries incurred by me while participating in the HFSN and the HFN program. 3. In consideration of being permitted to participate in any way in HFSN and the HFN travel and activities, I, for myself, my heirs, personal representative or assigns, do hereby release, waive, discharge, and covenant not to sue HFSN and the HFN, its officers, employees, and agents including, without limitation, Belinda Morse, from liability from any and all claims including the negligence of HFSN and the HFN, its officers, employees and agents, resulting in personal injury, accidents, or illnesses (including death) and property loss arising from, but not limited to, participation in the travel and activities. 4. I acknowledge that participation in the HFSN and the HFN travel and activities carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the travel and activities. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. Accordingly, I also agree to INDEMNIFY AND HOLD HFSN and the HFN and Board Members and Guardians HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees brought as a result of my involvement in the HFSN and the HFN travel and activities and to reimburse them for any such expenses incurred. The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Nevada and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. Verification: Enter any two numbers of your choice in the box below.Please enter any two digits of your choice *Example: 12This box is for spam protection - please leave it blank: