Online Veteran Application – Honor Flight Southern Nevada

Please use this form to complete your Veteran Application to Honor Flight Southern Nevada.

PLEASE BE AWARE: The Transportation Security Administration is reminding travelers that beginning October 1, 2020, every traveler must present a REAL ID-compliant driver’s license, or another acceptable form of identification, to fly within the United States

Online Veterans Application

Instructions

Please complete the following application to experience your Tour of Honor with Honor Flight Southern Nevada.

Once the application is submitted to Honor Flight Southern Nevada, we will review the application for completeness and be in touch.

Date *

Veteran Information

Name *

Provide your Full Name as shown on Driver's License or Government issued ID

If you do not have a Apt, Suite, Bldg. number, please enter "none"

Address *

Apt, suite, etc.

Country

City

State

Zip code

Home Phone *

Mobile Phone

Date of Birth *

Age *

Nickname for Nametag

Height *

Weight *

Gender *

Female

Male

Veteran Service History

Years of Service *

Please provide month/year for start and finish of your military career.

Served During which War *

World War II

Korean

Cold War

Vietnam

Check all that apply

Rank

Service Number

(if known)

Primary Location where you served: *

List your primary duty/duties: *

Please provide your primary duty/duties while you served:

Medals, Certificates, Commendations *

Please share any awards, certificates, commendations, conflicts, experiences or ribbons that are particularly meaningful to you:

Have you been on an Honor Flight before? *

Yes

If yes, Sorry you may only go on any Honor Flight once.

Emergency Contact Information

Emergency Contact *

Please provide who HFSN may contact in the event of an emergency.

If you do not have a Apt, Suite, Bldg. number, please enter "none"

Emergency Contact Address *

Apt, suite, etc.

Country

City

State

Zip code

Emergency Contact Phone *

Emergency Contact Email

Emergency Contact Relationship to Applicant: *

Emergency Contact Information - Secondary Contact

Emergency Contact No. 2 *

Please provide who HFSN may contact in the event of an emergency.

If you do not have a Apt, Suite, Bldg. number, please enter "none"

Emergency Contact No. 2 - Address *

Apt, suite, etc.

Country

City

State

Zip code

Emergeny Contact No. 2 - Phone *

Emergency Contact No. 2 - Email

Emergency Contact Relationship to Applicant: *

Guardian Information

(Spouses or "significant others" cannot be a guardian unless they are a veteran or seriously medically dependent)

Are you taking a guardian with you? *

Yes

If you chose No, HFSN will assign a guardian to you for your trip.

If Yes, did Guardian complete application?

Yes

The guardian application must be completed, and guardian is aware they pay for their trip costs of $900.

Guardian Name

If you do not have a Apt, Suite, Bldg. number, please enter "none"

Guardian Address

Apt, suite, etc.

Country

City

State

Zip code

Guardian Home Phone

Guardian Mobile Phone

Guardian Email

Relationship to Veteran

Place of Residence *

Private Home

Private Condo/Apartment

Indenpendent Living/Assisted Living

Nursing Home

Do you attend adult day care? *

Yes (if yes, complete information below)

How many days per week?

Do you use mobility equipment? *

Yes

Can you climb five stairs using handrails with minimal assistance? *

Yes

Have you suffered an injury from a fall in the past six months? *

Yes

If you answered "yes", please specify

Have you been hospitalized or had surgery in the past six months? *

Yes

If you answered "yes", please list surgery/hospitalizaton and dates below

Do you have diabetes? *

Yes

If you selected "yes", how do you control it?

Pill

Insulin

Diet

Do you have a pacemaker/defibrillator? *

Yes

Do you have a history of heart problems? *

Yes

If you selected "yes", please specific

Do you have a history of COPD or asthma? *

Yes

If you selected "yes", please describe:

Are you prescribed oxygen by your doctor? *

Yes

24 hours

As needed

With sleep apnea mask

Nightime only (not related to sleep apnea)

If yes, your private physician must write a prescription for oxygen to be used during the flight and/or day. HFSN can only supply oxygen concentrators at the hotel. You must supply the oxygen machine needed for the flight.

Do you use a home nebulizer machine? *

Yes

Do you use a CPAP machine? *

Yes

Do you suffer breathing problems? *

Yes

Breathing Problems *

If you selected "yes", please provide type of breathing problem.

Any history of heat exhaustion or difficulty breathing in the heat? *

Yes

Do you have any history of visual impairment (other than glasses)? *

Yes

If you selected "yes", please describe

History of neurological problems (i.e., Stroke, Parkinson's Disease)? *

Yes

If you selected "yes", please describe:

Do you suffer from seizures? *

Yes

Seizure Information *

If you selected "yes", please provide type of seizure

Provide date of your last seizure: *

If suffered seizure within the last five (5) years, please discuss the trip with your primary physician.

Do you suffer from motion sickness? *

Yes

If yes, can it be controlled through medication? *

Yes

If no, we strongly advise you consult your primary physician.

Instructions

The only health issue that would prevent your participation is Dementia or Alzheimer’s Disease.

Travel Concerns

Please document your medical history or conditions that would impact your travel.

History of Dementia or Alzheimer's OR are you on prescription medications for memory? *

Yes

Do you have incontinence concerns? *

Yes

If you selected "yes", are you able to handle any issues?

Yes

Do you have a foley, colostomy or urostomy bag? *

Yes

If yes, please make sure the bag is vented prior to the flight. If you are not sure if the bag has a vent, we strongly advise you consult your primary physician.

Are you currently undergoing dialysis? *

Yes

Do you smoke? *

Yes

Do you suffer from Allergies? *

Yes

If Yes to allergies, please list type of allergies:

Any reaction to bee stings? *

Yes

If you selected "yes" to bee sting, do you carry an epinephrine pen? *

Yes- You will need to bring with you on the trip.

Do you have any ear issues? *

Yes

Do you have any sinus issues? *

Yes

Have you flown since the head, ear or sinus problems occured? *

Yes

Did you have any problems in past flights? *

Yes

If yes, we strongly advise you discuss this trip with your primary physician.

Medication Information

In the box below, list ALL medicine, including dosage and frequency taken. Information provided WILL NOT disqualify you, however, we must ensure you are able to endure the travel.

If you take prescription medication, you are required to complete this table. If you do not provide your medication information, your application may be not be accepted.

Have your Physician provide a Medical History and list of your current prescriptions for you to take on the trip. It is strongly advised that you consult your private physician before making this trip.

Prescription List Information

If you have your medication information on a list, please take a photo and upload the photo.

I understand that if I do not complete my medical and current prescription information, my application may not be accepted by Honor Flight Southern Nevada. *

Yes

Your Primary Physician's Name: *

Primary Physican's Phone *

Date of your last Physical Exam? *

Medical Release

The information I have provided is complete and accurate. I understand that Honor Flight Southern Nevada medical volunteers will review my health history and may speak with my healthcare provider(s) to clarify any medical concerns. Honor Flight Southern Nevada must medically approve all participants to fly. I agree to notify Honor Flight Southern Nevada immediately should my medical condition change prior to the trip. If any of this information is falsified or pertinent medical information is omitted, or if my medical conditions change or are determined by Honor Flight Southern Nevada to be unacceptable to participate, I understand I may be disqualified from participating in an Honor Flight at the sole discretion of Honor Flight Southern Nevada. I understand that medical insurance and medical costs that may be incurred pursuant to participation are my responsibility and that Honor Flight Southern Nevada does not provide medical care. I understand that I accept all risks associated with travel and other Honor Flight Southern Nevada activities, and that I will sign a Release, Covenant Not to Sue and Indemnity agreement in favor of Honor Flight Southern Nevada while participating in the program. I hereby give consent and permission to any of my medical providers or emergency medical providers to discuss and release my health and treatment information for treatment purposes I may require during my participation in the Honor Flight Southern Nevada program and my signature on this page shall be sufficient evidence of my consent. My signature authorizes you to call my physician or any other personnel familiar with my care to discuss my medical history. Please note that a facsimile signature will also be accepted as an original signature.

PLEASE REVIEW CAREFULLY:

PLEASE TYPE YOUR NAME IN THE BOX BELOW, ACKNOWLEDGING YOU AGREE TO THE STATEMENTS BELOW *

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 of compensation or ownership thereto. 2. I further state that medical insurance is the responsibility of the veteran and I understand that HFSN and the HFN does NOT provide medical insurance. I understand that I accept all risks associated with travel and other HFSN and the HFN activities and will not hold HFSN and the HFN responsible for any injuries incurred by me while participating in the HFSN and the HFN program. By submitting this application electronically, you are signing that you have read and agree with the above statements.

Signature

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