LAKE COUNTY HONOR FLIGHT VETERAN APPLICATION

Transcription

1 LAKE COUNTY HONOR FLIGHT VETERAN APPLICATION LAKE COUNTY HONOR FLIGHT recognizes America s war veterans for their service and sacrifice by flying them to Washington D.C. to see their memorial, at no cost. Although we are currently flying WWII and Korean veterans, we are also accepting applications for Vietnam War veterans, as well. Our trips depart from General Mitchell International airport and may also depart from Chicago O Hare depending upon the schedule. You will be notified of the CONFIRMED trip date, time and assembly location when you are placed on the trip manifest. For further information, please contact Lenora Woods or Paula Carballido at (847) YOUR NAME: NICKNAME: (As it appears on your ID for airline travel) ADDRESS: CITY STATE ZIP PRIMARY PHONE: Day Night Cell Date of Birth: WEIGHT: TEE SHIRT SIZE: S M L XL XXL XXXL Gender: [ ] Male [ ] Female How did you hear about Lake County Honor Flight? I am a: [ ] WWII Veteran [ ] Korean War Veteran [ ] Vietnam Veteran LCHF USE ONLY: Last Name Date received: Conflict Board member Initial: Dates you served in the military (Month/Year to Month/Year): / to / Branch of service: [ ] Army [ ] Air Force [ ] Navy [ ] Marines [ ] Coast Guard [ ] Merchant Marines [ ]Other Rank: Service Number: Home Town (From which city and state did you enter the service)? Country(ies) where you served: Activity during the war:

2 Page 2 of 5 ADDITIONAL INFORMATION If you have a digital photo of yourself during your time in the service that you wish to share, please it along with your application. If mailing or faxing your application, you may the photo separately to LAKECOUNTYHONORFLIGHT.ORG Please DO NOT send original photos. Buddy & Guardian Information If you and a fellow veteran from the same war would like to travel together, please ask him/her to complete a Veteran Application. In addition, please include your buddy s name and number below so that we may try to pair you together on the same flight. Buddy s Name: Buddy s Phone: To help ensure a safe and memorable experience, LAKE COUNTY HONOR FLIGHT assigns each veteran his or her own personal companion for the day. These trained Guardians will provide excellent care and are responsible for being by the veteran s side throughout the trip. If you believe there is a medical need that necessitates that a specific relative or friend (aged 18-65) be considered to act as your guardian, please list that person s contact information below. Please also ask them to fill out a Guardian application found at which assures they will be considered, however selection is NOT guaranteed. Requested guardian name: Phone: Additional comments or concerns: Trip Duration Preference: [ ] Two Days [ ] Three Days (Sat-Sun/Hotel one night) (Fri-Sun/Hotel two nights) The undersigned acknowledges and agrees that the information on this application is correct. Please print your name and sign below it: Print Name: Signature: Date: If you are completing this application for your veteran, please print your name, relationship to the veteran and provide a phone number for us to contact you. Name: Phone Number: Relationship to Veteran: Please submit all pages of this form with required signature(s) as soon as possible to: Lake County Honor Flight or [email protected] Attn: Veteran Application 1850 Lewis Avenue North Chicago, IL 60064

3 Page 3 of 5 MEDICAL INFORMATION The purpose of this form is to provide Lake County Honor Flight and/or emergency medical technicians information about the participants should an emergency arise. NAME: ADDRESS: CITY: STATE: ZIP: Known allergies to medications: Known medical conditions MEDICATIONS (name and how often taken - If necessary, please attach additional sheets): Medication Taken how often? Medication Taken how often? EMERGENCY CONTACT INFORMATION In case of an emergency, please list the name, address and phone number of the person(s) you would like Lake County Honor Flight to contact on your behalf. Primary emergency contact (someone available the day you travel): Non-Spouse alternate contact (son, daughter, grandchild): Non-Spouse alternate contact (son, daughter, grandchild):

4 Page 4 of 5 The following medical information is necessary for Lake County Honor Flight s volunteer, medical and administrative staff to ensure that you have a safe and memorable day. Please check any mobility equipment used? [ ] Cane [ ] Walker [ ] Wheelchair [ ] Scooter If you are in a wheelchair, are you able to climb stairs with assistance? [ ] Yes Do you have a history of seizures? [ ] Yes Please describe: (i.e. grand mal, petit mal, other) When was your last seizure? Do you have problems with motion sickness (sea or air)? [ ] Yes If yes, is it controlled with medications? [ ] Yes Do you have any breathing problems? [ ] Yes If yes, please describe: Do you use oxygen at any time? [ ] Yes If yes, your private physician must write a prescription for oxygen to be used during the flight and during the tour. Do you smoke? [ ] Yes Do you have a problem walking the length of a football field unassisted? [ ] Yes If yes, please describe the reason (i.e. lung problems, arthritis, heart problems, etc.): Do you have diabetes? [ ] Yes If yes, injected or oral? [ ] Injected [ ] Oral Does your medication require refrigeration? [ ] Yes Do you carry glucose with you? [ ] Yes I hereby authorize Lake County Honor Flight organization, its officers, employees, members, participants, users and/or volunteers, to take the action they believe is appropriate in an emergency situation. Further, I agree to indemnify and hold harmless the Lake County Honor Flight organization, any officer, employee, member, participant, user and/or volunteer thereof, against any claim(s) arising out of said emergency care. DATE: SIGNATURE:

5 Page 5 of 5 A COVENANT NOT TO SUE AND INDEMNIFICATION AGREEMENT I,, am about to voluntarily participate in various activities, including (but not limited) to flying activities, of the Lake County Honor Flight Organization, as passenger. In consideration of (i) the Lake County Honor Flight Organization permitting me to participate in these activities and (ii) the entity providing free aircraft and flight service in connection with the Lake County Honor Flight (activities (the Flight Provider ), I, for myself, my heirs, administrators, executors and assigns, hereby covenant and agree that I will never institute, prosecute, or in any way aid in the institution or prosecution of, any demand, claim or suit against the Lake County Honor Flight Organization (including the organization known as The Honor Flight Network) or against the Flight Provider (collectively, the Released Parties ) for any destruction, loss, damage or injury (including death) to my person or property, whether or not now known or foreseeable, which may occur from any cause whatsoever as a result of my participation in the activities of the Lake County Honor Flight organization. If I, my heirs, administrators, executors, or assigns should demand, claim, sue or aid in any way in such a demand, claim or suit against the Released Parties in connection with my participation in the activities of the Lake County Honor Flight organization, I agree, for myself, my heirs, administrators, executors and assigns to indemnify the Released Parties for all damages, expenses, and costs it may incur as a result thereof. I know, understand, and agree that I am freely assuming the risk of my personal injury, death or property damage, loss or destruction that may result while participating in the Lake County Honor Flight activities, including such injuries, death, damage, loss or destruction as may he caused by the negligence of the Released Parties. I also understand and agree that I may be held liable for any damages or loss to the Lake County Honor Flight organization or to the Flight Provider which is caused by my gross negligence, willful misconduct, dishonesty or fraud and for limited damages or loss to the Lake County Honor Flight organization or the Flight Provider which is caused by my simple negligence. I further understand that the term Lake County Honor Flight organization includes the non-profit organization known as Honor Flight, any officer, agent and/or employee thereof. I further understand that the term Flight Provider includes any director, officer, agent, attorney, employee or affiliate thereof and any pilot, aircraft owner or others providing services to the Flight Provider. I understand and acknowledge that I may seek advice from legal counsel before signing this release. By signing this release, I acknowledge that either I have sought the advice of legal counsel or wish to now waive the opportunity to consult a lawyer before signing this release. SIGNATURE OF Lake County Honor Flight OFFICIAL: DATE: SIGNATURE: I authorize Lake County Honor Flight officials to release my contact information (home phone and address) to other requesting individuals who participate in the same flight for purposes of communication and camaraderie with other participants. Please circle one and initial: YES NO Initials