Central Missouri Honor Flight

CENTRAL MISSOURI HONOR FLIGHT

Veteran Application

Central Missouri Honor Flight recognizes American veterans for your sacrifices and achievements by flying you to Washington, DC to see YOUR memorial at no cost. Top priority (for which we are currently accepting application only) is given to WW II and terminally ill veterans from all wars. In the future, CM Honor Flight will be expanded to include Korean veterans. In order for CM 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 fellow veterans have given to us, please consider this a small token of appreciation from all of us at Central Missouri Honor Flight.  For further information, please contact Barbara Brueggeman at: (573) 301-5657 or email us at: centralmissourihonorflight@yahoo.com

Please Print Name as it appears on your photo ID (needed for airport security - TSA)

YOUR NAME: __________________________________________________________________________

(Please List Your First, Middle & Last Name)

First Name Preferred on Name Badge: ______________________________________

ADDRESS:_______________________________________________________________________________

CITY: ____________________________COUNTY:_________________ STATE: ________ ZIP:____________

PHONE: Day: ____________________ Evening: _________________Cell Phone: ______________________

E-MAIL ADDRESS: _____________________________ WEIGHT: _______ AGE: _______DOB:____________

HOW DID YOU HEAR ABOUT HONOR FLIGHT?__________________________________________________

TEE SHIRT SIZE: (M, L, XL, XXL, XXXL)  ________(You may wish to wear it over another shirt)

ALTERNATE CONTACT (son, daughter, etc): NAME______________________________________________

PHONE: ___________________ E-MAIL:___________________________ RELATIONSHIP: ______________

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: ___________________________________________________________________

________________________________________________________________________________________

DO YOU HAVE A WWII VETERAN THAT YOU WOULD LIKE TO TRAVEL WITH?     Yes:______  No:________
Name:___________________________________(We will make every effort to accommodate this request)

MEDICAL: INFORMATION PROVIDED WILL NOT DISQUALIFY YOU. IT PERMITS US TO ASSESS THE SUPPORT WE NEED TO PROVIDE YOU DURING THE TRIP. INFORMATION IS FOR CM HONOR FLIGHT AND MEDICAL PERSONNEL ONLY.  A PHYSICIAN ACCOMPANIES ALL FLIGHTS.

Do you use any mobility equipment? CANE:_____ WALKER:_____ WHEELCHAIR:_____ SCOOTER:_____

If yes, how often do you use your mobility equipment:_________________________________________

    MEDICATION               TAKEN HOW OFTEN?        MEDICATION                 TAKEN HOW OFTEN?

1.__________________    ___________________    4._________________     ____________________

2. _________________    ___________________     5. ________________      ____________________

3. _________________    ___________________     6.  ________________     ____________________

• Do you have any drug allergies?   YES   NO    Food allergies?  YES   NO

If yes____________________________________________________________________________

• Do you have a history of seizure?  YES   NO    Please describe what type (i.e. grand mal, petit mal, other) ________________________________When was your last seizure? _________. If within past 5 years, we STRONGLY advise you discuss trip with your private physician!
• Do you have problems with motion sickness (sea or air)?  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 private physician!
• Do you have any breathing problems?  YES   NO.

If YES, please describe: _____________________________________________________________

• Do you use a home nebulizer machine? YES   NO. If YES, you are STRONGLY encouraged to discuss the trip with your private physician concerning the use of portable hand-held nebulizers during the trip.
• Do you use oxygen at any time? YES NO.  When?___________________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 in Washington but, you will need to acquire an oxygen concentrator for air travel. The prescription should be turned in with the application.
• Do you have a problem walking the length of a football field without assistance?  YES   NO. If yes, please describe the reason (e.g. lung problems, arthritis, heart problems, etc.):__________________________________________________________________________
• 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, sinus or ear problems, again we STRONGLY advise you discuss the trip with your private physician.
• Do you have a urostomy (catheter) 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.
• Have you been diagnosed with Alzheimer’s Disease?  YES   NO

Additional Medical 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 CM Honor Flight 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 CM Honor Flight program. I hereby release the photographer and CM Honor Flight from all claims and liability relating to said photographs. I hereby give permission for my images captured during CM Honor Flight activities through video, photo, or other media, to be used solely for the purposes of CM Honor Flight 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 and I understand that neither CM Honor Flight nor the provider of free private aircraft ("Flight Provider") provides medical care. I understand that I accept all risks associated with travel and other CM Honor Flight activities and will not hold CM Honor Flight, the Flight Provider, or any person appearing or quoted in any advertisement or public service announcement for or on behalf of CM Honor Flight responsible for any injuries incurred by me while participating in the CM Honor Flight program.

SIGNED: ____________________________________________ DATE: ______________________________

(E-mail applicants will be required to sign prior to actual flight date)

Please submit this form to:  Central Missouri Honor Flight

                                                c/o KOMU TV

                                                5550 Highway 63 South

                                                Columbia, MO 65203