For Twin Tiers Honor Flight Use Only:
LAST NAME_____________________ DATE RECEIVED________
Veteran application
Twin Tiers Honor Flight recognizes American veterans for your sacrifice and achievements by
taking you to Washington, D.C. to see your memorial at no cost. Top priority is given to WWII,
Korean and Vietnam era veterans, but we also accept terminally ill veterans from any conflict. To
achieve this goal, guardians go with the veterans on every trip, providing assistance and helping
veterans have a safe, memorable and rewarding experience. For what you have given to us, please
consider this a small token of appreciation from all of us at Twin Tiers Honor Flight. For further
information, please contact us at 1-800-683-5403 or e-mail [email protected].
Name: __________________________________________________________________ Nickname (if any): __________________________________
(as it appears on your driver’s license or government ID)
Street Address: ____________________________________________________________________________________________________________
City/State/Zip: ____________________________________________________________________________________________________________
E-mail: _____________________________________________________________________________________________________________________
PHONE: Day: ________________________________ Eve: ___________________________ Cell: ______________________________________
Age: _____________________ DOB: _____________________ Gender: _____M _____ F
How did you learn about the Honor Flight organization? ____________________________________________________________
T-shirt size:
S
M
L
XL
XXL
XXXL
EMERGENCY CONTACT INFORMATION (someone available the day you travel):
Name: __________________________________________________ Relationship to applicant: ____________________________________
Street Address: ____________________________________________________________________________________________________________
City/State/Zip: ____________________________________________________________________________________________________________
E-mail: _____________________________________________________________________________________________________________________
PHONE: Day: ________________________________ Eve: ___________________________ Cell: ______________________________________
ALTERNATE CONTACT (son, daughter, etc.)
Name: __________________________________________________ Relationship to applicant: ____________________________________
Street Address: ____________________________________________________________________________________________________________
City/State/Zip: ____________________________________________________________________________________________________________
E-mail: _____________________________________________________________________________________________________________________
PHONE: Day: ________________________________ Eve: ___________________________ Cell: ______________________________________
SERVICE HISTORY
Branch Of Service: ________________________________________ Rank: ___________________________________________
Conflict Era In Which You Served: ________ WWII, ________ Korea, ________ Vietnam, ________ Other
World War II: (December 7, 1941 – December 31, 1946)
Vietnam: (February 28, 1961 – May 7, 1975)
Korean: (June 27, 1950 – January 31, 1955)
Activity During Wartime: _________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
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MEDICAL INFORMATION
The information supplied on this form will not disqualify you from a flight. This information is strictly confidential
and is used by the medical team to ensure your medical safety on this trip.
Mobility:
Y__ N__
Are you able to walk 100 yards (the length of a football field) without stopping to rest?
Y__ N__
Do you use any mobility equipment?
If yes what type?
__Cane
__Walker
__Motorized Wheelchair
__Wheelchair
__Motorized Scooter
Y__ N__
Are you be able to walk the length of the jet way to board the plane?
Y__N__
Is your weight greater than 250 pounds? If so what is your weight?_______
Medications:
Y__ N__
Do you have any food or drug allergies?
If so please list: ______________________________________________________________.
Y__ N__
Do you experience an anaphylactic reaction to this medication or food?
Y__ N__
Do you use an Epi-Pen? If yes, make sure you bring it on the trip.
MEDICATION
Dosage (mg mcg ect.)
(Frequency) times per day
Please remember all medications must be in pharmacy-labeled prescription bottles per TSA guidelines.
If additional space is needed or if you have a printout of your medications, Please attach it to this form instead of
completing medication boxes.
Y__ N__
Do you have a history of seizures?
If yes, date of last seizure ______________ Type of seizure_____________________
Y__ N__
Do you require any help with self-care or toileting?
Y__ N__
Y__ N__
Do you have a history of motion sickness?
If yes, are you bringing medication to control symptoms?
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Y__ N__
Do you have breathing problems?
If yes, type of problem ___________________________________________________________
Y__ N__
Are you a diabetic?
Y__ N__
Do you require insulin? Please bring glucose monitor on the trip.
Y__ N__
Do you have heart (cardiac) problems?
If yes, when and what type ________________________________________________________
Y__ N__
Do you use nitroglycerin for chest pain?
If yes, how often do you need it? ______________
Y__ N__
Will you need oxygen for the trip?
Only portable oxygen concentrators allowed on flight. No oxygen tanks are
permitted on the flight.
If yes, make and model___________________________________________________________
Y__ N__
Will you be using a nebulizer on the trip?
If yes, make and model___________________________________________________________
Y__ N__
Do you have a history of an open head injury?
If yes, when and what type________________________________________________________
Y__N__
Do you have any issues with memory or dementia?____________________________
Y__ N__
Do you have a history of any sinus or ear problems that would be problematic when flying?
If yes, when and what type________________________________________________________
Y__ N__
Do you use a urostomy or colostomy bag? Please make sure bag is vented prior to flight.
Y__ N__
Do you have any vision difficulties?
If yes when and what type________________________________________________________
Y__ N__
Do you have any hearing difficulties?
If yes when and what type________________________________________________________
Y__ N__
Do you require an ADA (handicapped) hotel room? FOR BUS TRIPS ONLY
Please List Any Additional Medical Information of which, the medical team should be aware.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
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PLEASE REVIEW CAREFULLY AND SIGN:
The undersigned acknowledges and agrees that:
1. As photographic and video equipment are frequently used to memorialize and document Twin Tiers 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 Twin Tiers Honor Flight program. I hereby release the
photographer and Twin Tiers Honor Flight from all claims and liability relating to said photographs. I
hereby give permission for my images captured during Twin Tiers Honor Flight activities through video,
photo, or other media, to be used solely for the purposes of Twin Tiers 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
Twin Tiers Honor Flight nor the provider of transportation provides medical care. I understand that I
accept all risks associated with travel and other Honor Flight Network activities and will not hold Twin
Tiers Honor Flight, the transporter, Honor Flight Network, or any person appearing in or quoted in any
advertisement or public service announcement for or on behalf of Twin Tiers Honor Flight or Honor Flight
Network responsible for any injuries incurred by me while participating in the Honor Flight program.
Signed: __________________________________________________________________________________________________________________*
Date (Month, day, year): ______________________________________________________________________________________________
*E-mail applicants will be required to sign hard copy prior to actual flight date
Please submit this form to:
Twin Tiers Honor Flight
2735 Slaterville Road
Brooktondale, NY 14817-9507
Or send to:
[email protected]
Questions:
1-800-683-5403
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TWIN TIERS HONOR FLIGHT MEDICAL POLICIES AND INFORMATION
Twin Tiers Honor Flight is privileged to have an experienced volunteer medical team to accompany you
on your flight. Our medical team does not disqualify individuals with medical conditions as long as they
are able to ensure that you are able to travel safely and comfortably. We ask that you are honest and
completely fill out the medical questionnaire. Your medical information is strictly confidential and will
only be viewed by our medical staff and flight coordinator.
The medical director for this flight is:
Contact number is:
TBA
Please feel free to contact her for any medical concerns or if your
medical condition changes in any way prior to the flight.
General Medical Information:

All prescription medications need to be in original prescription bottles.

No oxygen cylinders are permitted on the aircraft. If you will be using oxygen for the Honor Flight
arrangements will need to be made to obtain a portable oxygen concentrator. If you need
assistance with making arrangements for this we will be happy to help you.

If you will require the use of a nebulizer while on the flight we will need the make and model at
least one month prior to flight for clearance with TSA (there are certain approved
manufacturers).

Please do not bring personal wheelchairs on the flight. We will have wheelchairs available for
your use. If you have modifications for your personal wheelchair, please notify us and we can
assist you.
It is strongly recommended that you discuss the trip with your doctor to ensure you are medically
stable for travel.
To contact Twin Tiers Honor Flight for reasons other than medical, please call: 1-800-683-5403
PLEASE DETACH AND KEEP THIS PAGE FOR YOUR RECORDS
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