Veteran Online Application | Honor Flight Central Coast California

We suggest that you scroll down and look at what information will be needed before you start filling this out. You may need to gather information such as Emergency Contact and Physician Contact information along with all your medications. Alternatively, you can fill out a paper application – click here.

Note: You will be required to present your DD214 (or other approved military service record if your DD214 isn’t available) before going on a trip. When your trip is scheduled, you will be given instructions on when to show us your document. Please do not send it in.

* indicates a required field.

Veteran Application

Full legal name as it appears on either your ID or passport. Provide a copy of the same ID you will show at the airport.*
First Middle Last
Please provide a copy of the same photo ID that you will show at the airport with this application.
Accepted file types: pdf, jpg, jpeg, png, gif, Max. file size: 2 MB.
If you can upload a copy of the photo ID that you will use at the airport, please do so (max file size 2MB). If you can't upload the file, please send a copy to us ASAP via USPS (PO Box 1750, Paso Robles CA 93447). NOTE: Your application will be put on hold until this is received.
Preferred name or nickname
Address*
Street Address City State ZIP Code
Primary phone*
Type*
Secondary phone
Type
Email
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Men's T-Shirt size*
Men's Jacket Size*
Service History
Branch of Service*
Rank (not pay grade)
When did you serve: From (month/year)*
When did you serve: To (month/year)*
In what war era(s) did you serve? (select all that apply)*
- WWII
- Korea
- Pre Vietnam
- Vietnam
- Post Vietnam
If Post Vietnam, please specify:
If Post Vietnam, please specify:
Military MOS and job description
Additional comments of military history
Emergency Contact Information
Name*
Relationship*
Primary phone*
Type*
Secondary phone
Type
Additional Emergency Contact
Please fill out an an additional emergency contact for someone living outside your home. If there is none please enter "none" in the fields and a bogus phone number.
Name*
Relationship*
Primary phone*
Type*
Secondary phone
Type
Additional Information
Will a family member or caregiver (cannot be your spouse or significant other) be traveling with you as your guardian*
Guardian Name*
Relationship*
Phone*
Type*
Email
Medical Information
This permits us to assess the support we may need to provide during the trip including emergencies. Information is for Honor Flight and medical personnel only. A medical release form may be required from your physician. Attach a copy of your Do Not Resuscitate (DNR) order if those are your wishes.
Medications*
To add more medications click the "+" at the right of the row. If you have none, enter "none".
Medication Taken Dosage How Often
Please list your physician's name and phone number in case of an emergency.
Physician's Name*
Phone*
Do you want to include your DNR?*
Attach your DNR
Accepted file types: pdf, jpg, Max. file size: 5 MB.
If you have a DNR and want us to have it, please upload it. If you can't upload it now you can get it to us before the trip (max file size 5MB).
Do you have any special dietary needs?*
Check all that apply. If you choose "Other" you will have an opportunity to describe it.
- None
- Vegetarian
- Vegan
- Diabetic
- Low Salt
- Gluten Free
- Other
You chose "Other" as a special dietary need. Please tell us what it is.
Do you have any drug allergies?*
Please list drugs that you are allergic to
Do you use mobility equipment?*
How often do you use mobility equipment?
Which mobility devices do you use (select all that you use)?
- Cane
- Walker
- Wheelchair
- Scooter
Do you have a history of seizures?*
Please describe what type of siezures that you have (e.g. grand mal, petit mal, other)
Date of last seizure
Month
Day
Year

If you have had a seizure within the last 5 years we strongly advise you to discuss this trip with your physician.
Have you been diagnosed with dementia or are you taking any medications for dementia?*
Are you able to provide all self-care independently (eating, bathing, and dressing)?*
What help is needed?
Do you have problems with motion sickness?*
Is your motion sickness controlled with medications?
If your motion sickness is not controlled by medications it is strongly advised that you discuss this trip with your physician.
Do you use a nebulizer machine?*
If you use a nebulizer machine it is strongly advised that you discuss the use of portable hand-held nebulizers during this trip with your physician.
Do you have breathing problems?*
Please describe your breathing problems.
Do you use oxygen at any time?*
If you use oxygen you will need your physician to write a prescription for oxygen to be used during the flight and during the tour. The prescription must be turned in with the application and oxygen will be provided in Washington D.C.
Do you have difficulty walking the length of a football field?*
Please describe the reason that you have problems walking a distance (e.g. lung problems, arthritis, heart problems, etc)?
Do you have a history of open head injuries, sinus problems, or ear problems?*
Have you flown since the open head injury, sinus or ear problem?
Did you have any problems when you flew before?
It is strongly advised that you discuss the trip with your physician. If you have NOT flown since the open head injury, sinus or ear problem began, we strongly advise you to discuss the trip with your physician.
Do you have urostomy or colostomy bag?*
Please make sure your bag is vented prior to flight. If you do not know if your bag is vented, it is STRONGLY advised that you discuss this with your physician.
Consent
Please Review. You will be asked to sign this later
1. As photographic and video equipment are frequently used to memorialize and document Honor Flight Central Coast California (HFCCC) and the Honor Flight Network (HFN) trips and events, my image may appear in a public forum, such as the media or a website, to acknowledge, promote or advance the work of the HFCCC and the HFN program. I hereby release the photographer and HFCCC and the HFN from all claims and liability relating to said images. I hereby give permission for my images captured during HFCCC and the HFN activities through video, photo or other media, to be used solely for the purposes of HFCCC and the HFN promotional materials and publications, and waive any rights of compensation or ownership thereto.

2. I further state that medical insurance is NOT the responsibility of HFCCC or HFN. I understand that HFCCC and the HFN does NOT provide medical care. I understand that I accept all risks associated with travel and other HFCCC and the HFN activities and will not hold HFCCC and the HFN responsible for any injuries incurred by me while participating in the HFCCC and the HFN program

3. HFCCC provides flight cancellation and liability insurance for those listed on the HFCCC airline sponsored manifest.

4. Refunds are dependent on the amount of funds that are returned to HFCCC from purchases made previously on the guardian’s behalf.

5. The Veteran agrees to indemnify and hold the Honor Flight Central Coast California (HFCCC) and its board members harmless from and against any and all claims, liability, loss, expenses, suits, damages, judgments, demands, and costs (including reasonable legal fees and expenses) arising out of (i) the acts or omissions of HFCCC or its board members in connection with Tour of Honor or related events; or (ii) any accident, injury or death to persons, or loss of or damage to property, or fines and penalties which may result, in whole or in part, on a Tour of Honor or related events.

6. I understand that the HFCCC Board reserves the right to deny any application at the Board’s discretion.

Don't worry about signing it online. We will get your signature at a later date.
Signature: ________________________________________ Date: _______________________

Medication Taken	Dosage	How Often

Veteran Application

Service History

Emergency Contact Information

Additional Emergency Contact

Additional Information

Medical Information

Consent

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