Veteran Application

Contact Info

Title

First Name*

Middle Name

Last Name*

Suffix

Email*

Phone

Ext

Work
Mobile
Home

Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country *

Additional Information for Your Application(s)

1 X Veteran Application for Southwest FL Honor Flight

Badge Nickname:*

ZIP:*

Primary Phone:*

Birthdate:*

T-Shirt Size:*

Weight (must have for airline manifest):*

Height: (Ft, Inch)*

SERVICE HISTORY

Hometown:

Military Branch:*

Rank:*

Service Dates:

From:

To:

Career Field/Units Assigned/Locations INCLUDED any special condemnations:*

Special condemnations: (please list any military honors/models you received)*

Please submit a copy of your DD214 documents or a copy of your VA card and your Driver's license or state-issued ID card.

Veteran's Name:

VETERAN CONTACTS

Spouse

Spouse Name:

Spouse Street Address:*

Spouse City:*

Spouse State:*

Spouse ZIP:*

Spouse Primary Phone:*

Spouse Cell Phone:*

Spouse Email Address:*

In case of Emergency, call(someone available the day you travel and not traveling with you)

Emergency Contact Name:

Emergency Contact Relationship:*

Emergency Contact Street Address:*

Emergency Contact City:*

Emergency Contact State:*

Emergency Contact ZIP:*

Emergency Contact Primary Phone:*

Emergency Contact Cell Phone:*

Emergency Contact Email Address:*

If you would like to have a specific relative or friend serve as your Guardian Escort, please provide his/her name and phone number. (Must be the age of 18 and able to handle the rigors of the day). He/she must submit a Guardian application and pay guardian fees. (available at www.swflhonorflight.org).

Requested Guardian Name:

Guardian Phone number:*

Relationship of Guardian:*

Guardian Email Address:*

If you wish to experience your trip to Washington, D.C. with a Veteran buddy, please list his/her name and phone number. Your Buddy must also submit an application and we suggest submitting your application together.

Veteran Buddy's Name:

VETERAN MEDICAL INFORMATION

Please list any chronic illnesses (i.e., cancer, Parkinson's, heart issues, etc.) and the date of diagnosis: (Information is for scheduling purposes and does not exclude you from a trip.)

Do you normally use mobility assistance?

Note: We provide a wheelchair for every Veteran and will not take a personal wheelchair, walker, or Motorized Unit on the trip. You may bring a personal cane if desired.

Are you able to go up/down 6 steps to get on/off the bus with help?*

Do you have a history of Epilepsy or seizures?

If Yes, please describe:(i.e., grand mal, petit mal, other)

Have you had a stroke?

If Yes, when?

Are you short of breath after exerting yourself?*

Do you carry an inhaler?*

Do you use Oxygen at any time?*

Do you have kidney problems?*

Are you on dialysis?*

Do you have a urostomy or colostomy bag?

Note: If Yes, please make sure the bag is vented prior to flight. If you do not know if your bag is vented, you must discuss the issue wit your private physician.

Are you Diabetic?*

Does your medication require refrigeration?*

Do you carry glucose with you?

Note: If you are insulin dependent, your physician must write a prescription for insulin to be used during the trip.

Do you have a pacemaker/internal defibrillator?*

Please list any food or drug allergies:*

Please list any food restrictions:*

Please list any other area(s) of concern:*

Are you a Snowbird?

Snowbird Address:

How did you find out about Honor Flight?

Your application will be entered into our database based on the date received. Priority goes to any terminally ill Veteran, then WWII Vets (service 1948 and earlier), then Korean War Vets (service 1950-1955), then Vietnam (service 1955-1975), and then any service 1976 to the present.

Read and Sign Waiver

Please Review Carefully and Sign<br />
The undersigned acknowledges and agrees that:<br />
<br />
1. I state that the information provided in this application reflects a true and accurate summary of my<br />
personal status to the best of my ability.<br />
2. I also state that I understand that personal medical insurance is my responsibility and I understand that<br />
Southwest Florida Honor Flight does not provide medical care for me. I understand that I accept all<br />
risks associated with travel and other Southwest Florida Honor Flight activities and will not hold<br />
Southwest Florida Honor Flight staff, Honor Flight volunteers or vendors encountered during related<br />
activities responsible for any injuries or illness incurred by me while participating in the Southwest<br />
Florida Honor Flight program.<br />
3. As photographic, video, and audio equipment are frequently used to memorialize and document Honor<br />
Flight trips and events, my image may appear in a public forum, such as the media or a website, to<br />
acknowledge, promote, or advance the work of the Honor Flight program. I hereby release the<br />
videographer/photographer and Southwest Florida Honor Flight from all claims and liability relating to<br />
said images. I hereby give permission for my images captured during Honor Flight activities through<br />
video, photo, or other media, to be used solely for the purposes of Honor Flight promotional material<br />
and publications, and waive any rights of compensation or ownership thereto.<br />
4. You must attend a MANDATORY orientation (generally the Saturday prior to the flight). After<br />
submitting an application, you must be approved by SWFL Honor Flight leadership to participate. You<br />
will be contacted by a representative so it is important that the above information is legible and<br />
accurate.

I accept the terms of the waiver.

Your birthdate

IP: 216.73.217.43
Apr. 30, 2026

By clicking I agree to the terms.