Operation at Ease DESERT VETERAN APPLICATION Old Glory Honor Flight proudly announces Operation at Ease, a one-­‐time opportunity for Desert Veterans to visit the Middle East Conflicts Wall. The memorial was built to honor the service and to recognize the many sacrifices of our most recent service men and women. There is no cost to the veteran and preference will be given to veterans residing in the Northeast Wisconsin region. ** Please note** Operation at Ease is a one-­‐time only event. Applications received will be chosen by random drawing for a free, one-­‐day bus tour to Marseilles, IL to visit the Middle East Conflicts Wall on Saturday, October 17th, 2015. A maximum of 150 veterans will be selected to participate. Applications must be received by September 18th, 2015 to be eligible YOUR FULL NAME: _______________________________________________ ADDRESS: _________________________CITY: ________________STATE: WI ZIP: ___________ CELL PHONE: ________________________ T-­‐SHIRT SIZE: S, M, L, XL, 2XL, 3XL, 4XL (circle one) EMAIL ADDRESS: ______________________________________ AGE: _______Date of Birth: ____________ BRANCH OF SERVICE: _______________ RANK: ___________DATES OF SERVICE: ________________ Unit(s)__________________________MOS____________ Area of Operation________________________ Any specifics regarding your service ex: citations, experiences? We often use this information to match vets with similar background. __________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ EMERGENCY CONTACT INFORMATION ON THE DAY YOU TRAVEL. (Please list two): Name___________________________________ Relationship:____________________________ Phone: ____________________ ___Cell Phone: _________________________ Name___________________________________ Relationship:____________________________ Phone: ____________________ ___Cell Phone: _________________________ We cannot accept entries after September 18th, 2015. Please note: we expect many more applications than we can accommodate for this bus trip. We wish we could take each and every vet who applies but we have limited seats. An Old Glory Honor Flight volunteer will contact you if your application was chosen (by random drawing) by September 19th, 2015. Thank you for your patience & understanding, and most of all, thank you for your service! Medical Information: The following Information helps us assess the support we need during the trip. This information is for Old Glory Honor Flight and its medical volunteers only. MEDICAL HISTORY Do you have any of the following? PLEASE CIRCLE DIABETES YES NO Insulin Dependent? YES NO HEART CONDITION / ANGINA YES NO ASTHMA YES NO Do you use an inhaler? YES NO KIDNEY DIALYSIS YES NO OTHER MEDICAL CONCERNS? Please explain ________________________________________________________________________________________
________________________________________________________________________________________ PLEASE LIST ALL CURRENT MEDICATIONS, DOSE, FREQUENCY 1._______________________________________ 2._______________________________ 3._______________________________________ 4._______________________________ 5._______________________________________ 6._______________________________ DO YOU HAVE ANY DRUG OR FOOD ALLERGIES? Please list:_____________________________________ DO YOU USE (CIRCLE ALL THAT APPLY) CANE WALKER WHEELCHAIR OR PROSTHETICS? IF YES, DO YOU ANTICIPATE THE NEED FOR THE USE OF A WHEELCHAIR DURING THE DAY? ___________ IF YES WE WILL ACCOMMODATE AND PROVIDE. **CERTIFIED SERVICE OR THERAPY DOGS WILL BE ALLOWED TO ACCOMPANY THE VETERAN** PLEASE REVIEW CAREFULLY, INITIAL EACH LINE & SIGN: The undersigned acknowledges and agrees that: ___I hereby give permission for my name to be released to other event participants via a flight roster. Information will include veteran name, phone number, address and branch of service. ___I hereby give permission for my images captured during Old Glory Honor Flight activities through video, photo, audio, or other media, to be used solely for the purposes of Old Glory Honor Flight promotional material, publications, and news reporting and I waive my rights of compensation for or ownership of such material. ___I understand that medical insurance is my responsibility and I understand that neither Old Glory Honor Flight Inc nor the transportation provider provides medical care. I understand that medically trained persons participating in the event are doing so as Good Samaritans and not as medical professionals. I understand that I accept all risks associated with travel and other honor flight activities and will not hold Old Glory Honor Flight Inc., its sponsors, organizers, volunteers, or any person/group for any injuries incurred while participating in the honor flight program. ___I understand that Old Glory Honor Flight Inc. strongly recommends I discuss this trip with my private physician prior to event date. ___I understand that my spouse or other family members may not accompany me on this trip. ___ Old Glory Honor Flight, Inc. supports the constitution and the amendments that you swore oath to and fought to protect. However, The Peoples Republic of Illinois does not recognize concealed carry permits from the state of Wisconsin. I understand weapons are not allowed on this trip of honor. ___I understand that I am applying to participate as a passenger in various activities, including travel, of Old Glory Honor Flight, Inc. In consideration of this organization permitting me to participate in these activities, I, for myself, my estate, 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 organization known as Old Glory Honor Flight Inc., or its sponsors or partners for any destruction, loss, damage or injury (including death) to my person or property which may occur from any cause whatsoever as a result of my participation in the activities of the Old Glory Honor Flight Inc. ___If I, my heirs, administrators, executors or assigns should demand, claim, sue or aid in any way in such a demand, claim or suit, I agree, for myself, my estate, my heirs, administrators, executors, and assigns to indemnify Old Glory Honor Flight, Inc 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 Old Glory Honor Flight activities, including such injuries, death, damage, loss or destruction as may be caused by the negligence of the Old Glory Honor Flight organization. ___I also understand and agree that I may be held liable for any damages or loss to the Old Glory Honor Flight organization which is caused by my gross negligence, willful misconduct, dishonesty or fraud and for limited damages or loss to the Old Glory Honor Flight organization which is caused by my simple negligence. SIGNED: ________________________________________________Date:___________________ Questions? Email us at [email protected] Please submit this application before September 18th to: Old Glory Honor Flight Operation at Ease PO Box 7230 Appleton, WI 54912