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LAKE COUNTY HONOR FLIGHT
VETERAN APPLICATION
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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.
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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) 282-0374.
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YOUR NAME: _________________________________ NICKNAME: __________________________ (As it appears on your ID for airline travel)
ADDRESS: _________________________CITY_________________ STATE ________ ZIP _________ PRIMARY PHONE: Day____________________ Night _________________Cell__________________
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Date of Birth: ________________ WEIGHT: _____ TEE SHIRT SIZE: S M L XL XXL XXXL
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Gender: [ ] Male [ ] Female How did you hear about Lake County Honor Flight? ______________ _____________________________________________________________________________________
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I am a: [ ] WWII Veteran [ ] Korean War Veteran [ ] Vietnam Veteran
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Dates you served in the military (Month/Year to Month/Year): _______ /_______ to ________ /_______
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Branch of service: [ ] Army [ ] Air Force [ ] Navy [ ] Marines [ ] Coast Guard
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.
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Buddy’s Name: ________________________________ Buddy’s Phone: __________________________
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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 www.honorflight.org. which assures they will be considered, however selection is NOT guaranteed.
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Requested guardian name: _______________________________ Phone:__________________________ Additional comments or concerns:_________________________________________________________
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: ____________________________
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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: _________________________________________________________________
ADDITIONAL INFORMATION
If you have a digital photo of yourself during your time in the service that you wish to share, please email it along with your application. If mailing or faxing your application, you may email the photo separately to LAKECOUNTYHONORFLIGHT.ORG Please DO NOT send original photos.
Trip Duration Preference:! ! [ ] Two Days ! [ ] Three Days ! (Sat-Sun/Hotel one night)! ! (Fri-Sun/Hotel two nights)
Please submit all pages of this form with required signature(s) as soon as possible to: Lake County Honor Flight or Email: [email protected] Attn: Veteran Application
MEDICAL INFORMAT
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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 _______________________________________________________________ _____________________________________________________________________________________
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MEDICATIONS (name and how often taken - If necessary, please attach additional sheets): Medication Taken how often? Medication Taken how often? _____________________ _______________ _____________________ _______________ _____________________ _______________ _____________________ _______________ _____________________ _______________ _____________________ _______________ _____________________ _______________ _____________________ _______________
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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):
Name: _______________________________________ Relationship:_____________________________ Address: ________________________________ City: ________________________ State:___________ Phone: Day______________________ Evening ______________________ Cell____________________ Email: _______________________________________________________________________________
Non-Spouse alternate contact (son, daughter, grandchild):
Name: _______________________________________ Relationship:_____________________________ Address: ________________________________ City: ________________________ State:___________ Phone: Day______________________ Evening ______________________ Cell____________________ Email: _______________________________________________________________________________
Non-Spouse alternate contact (son, daughter, grandchild):
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.
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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 [ ] No
Do you have a history of seizures? [ ] Yes [ ] No 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 [ ] No
If yes, is it controlled with medications? [ ] Yes [ ] No
Do you have any breathing problems? [ ] Yes [ ] No If yes, please describe: __________________ Do you use oxygen at any time? [ ] Yes [ ] No 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 [ ] No
Do you have a problem walking the length of a football field unassisted? [ ] Yes [ ] No
If yes, please describe the reason (i.e. lung problems, arthritis, heart problems, etc.): _________________ _____________________________________________________________________________________ Do you have diabetes? [ ] Yes [ ] No
If yes, injected or oral? [ ] Injected [ ] Oral
Does your medication require refrigeration? [ ] Yes [ ] No Do you carry glucose with you? [ ] Yes [ ] No
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A COVENANT NOT TO SUE AND INDEMNIFICATION AGREEMENT
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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.
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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.
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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.
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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.
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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.
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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.
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DATE: _____________ SIGNATURE: _____________________________________________________
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SIGNATURE OF Lake County Honor Flight OFFICIAL: ______________________________________
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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___________