Twin Tiers Honor Flight | Guardian Registration Form

First Name

Middle Name

Last Name

Nickname (if used)

Date of Birth

Gender

Male Female

Street Address

City

State

Zipcode

County

Daytime Phone

Evening Phone

Mobile Phone

Email Address

Are you a Veteran?

Yes No

Branch of Service (check all that apply) Army Navy Air Force Marines Coast Guard Other

Conflicts during your service (check all that apply) WW II (Dec. 7, 1941 - Dec. 31, 1946) Korea (June 29, 1950 - Jan. 31, 1955) Vietnam (Feb. 28, 1961 - May 8, 1975) Lebanon/Grenada (Aug. 24, 1982 – Dec. 15, 1983) Panama (Dec. 20, 1989 – Feb. 13, 1990) Gulf War / War on Terrorism (Aug. 2, 1990 - Present) Other Dates

Note: Please see the attached CRS document for any clarification of Conflict dates

Service Dates / Comments:

Activity during your service period including Duty Assignments

Form and type of discharge received from the military (if applicable):

First Name

Last Name

Relationship

Address

City

State

Zipcode

Daytime Phone

Evening Phone

Mobile Phone

Email Address

First Name

Last Name

Relationship

Address

City

State

Zipcode

Daytime Phone

Evening Phone

Mobile Phone

Email Address

What is your Weight?

What is your Height?

Do you use mobility equipment? (check all that apply)

Cane

Scooter

Walker

Wheelchair

Wheelchair (Wide)

Can you walk up & down a set of eight bus steps with assistance?

Yes No

Medications

Surgeries

Do you have any drug allergies?

Yes No

Do you have any food allergies?

Yes No

Do you have a history of seizures?

Yes No

Do you have problems with motion sickness (sea or air)?

Yes No

Do you have any breathing problems?

Yes No

Do you use a home nebulizer machine?

Yes No

Do you use oxygen at any time?

Yes No

Do you have a problem walking the length of a football field without assistance?

Yes No

Do you have a history of open head injuries, sinus problems, or ear problems?

Yes No

Are you claustrophobic?

Yes No

Are you visually impaired?

Yes No

Are you deaf or hard of hearing?

Yes No

Do you have a urostomy, colostomy, or urinary catheter?

Yes No

Have you been diagnosed with memory problems?

Yes No

Cognition / Sundowning?

Yes No

Do you use insulin?

Yes No

Do you wear or have a heart pacemaker implanted?

Yes No

Do you have any condition(s) (not mentioned above) or circumstances which might limit your ability to travel with a commercial airline, or could limit your ability to physically participate in this event?

Do you require a special meal?

Yes No

Do you have a Living Will or Advance Directive?

Yes No

Do you have Medical Insurance?

Yes No

Have you been the recipient of a previous Honor Flight trip or visited the WW II, Korean, Marine Corps or Vietnam War Memorials?

Yes No

T-Shirt Size

Are you willing to assist all veterans, and are you willing to push any wheelchair?

Yes No

Can you lift 100 pounds?

Yes No

Are you requesting to travel with a specific veteran, if possible?

Yes No

Occupation:

Why are you volunteering for Honor Flight?

Please list any prior Volunteer experience:

Remarks / Comments:

How did you hear about Honor Flight?