Veteran Form 2021

First Name*

Middle Name

Last Name*

County* —Please choose an option—Adair CountyAllen CountyAnderson CountyBallard CountyBarren CountyBath CountyBell CountyBoone CountyBourbon CountyBoyd CountyBoyle CountyBracken CountyBreathitt CountyBreckinridge CountyBullitt CountyButler CountyCaldwell CountyCalloway CountyCampbell CountyCarlisle CountyCarroll CountyCarter CountyCasey CountyChristian CountyClark CountyClay CountyClinton CountyCrittenden CountyCumberland CountyDaviess CountyEdmonson CountyElliott CountyEstill CountyFayette CountyFleming CountyFloyd CountyFranklin CountyFulton CountyGallatin CountyGarrard CountyGrant CountyGraves CountyGrayson CountyGreen CountyGreenup CountyHancock CountyHardin CountyHarlan CountyHarrison CountyHart CountyHenderson CountyHenry CountyHickman CountyHopkins CountyJackson CountyJefferson CountyJessamine CountyJohnson CountyKenton CountyKnott CountyKnox CountyLarue CountyLaurel CountyLawrence CountyLee CountyLeslie CountyLetcher CountyLewis CountyLincoln CountyLivingston CountyLogan CountyLyon CountyMadison CountyMagoffin CountyMarion CountyMarshall CountyMartin CountyMason CountyMcCracken CountyMcCreary CountyMcLean CountyMeade CountyMenifee CountyMercer CountyMetcalfe CountyMonroe CountyMontgomery CountyMorgan CountyMuhlenberg CountyNelson CountyNicholas CountyOhio CountyOldham CountyOwen CountyOwsley CountyPendleton CountyPerry CountyPike CountyPowell CountyPulaski CountyRobertson CountyRockcastle CountyRowan CountyRussell CountyScott CountyShelby CountySimpson CountySpencer CountyTaylor CountyTodd CountyTrigg CountyTrimble CountyUnion CountyWarren CountyWashington CountyWayne CountyWebster CountyWhitley CountyWolfe CountyWoodford CountyOTHER - NOT KENTUCKY

Mailing Address*

City*

State*

ZIP*

Daytime Phone*

Cell Phone*

Email Address*

T-shirt Size: --Select size--XSSMLXLXXL3XL4XL5XL

Date of Birth*

Age*

Spouse's Name

Spouse's Daytime Phone*

Spouse's Cell Phone*

Requested Flight Information (Were you told to use a date or code for a flight? If so, enter that here. If not, leave blank):

Emergency Contact (someone who will be available day of travel)

Relationship to the Emergency Contact

Emergency Contact Daytime Phone

Emergency Contact Cell Phone

Please enter your branch of service*

Please enter your rank*

Please enter the year range of which you served in the military (in this format: 1955-1964)*

What were your military duties?*

Where were you stationed?*

Were you awarded any medals?

Is there someone you want to go with you as your Guardian? (Please note: spouses are not allowed to serve as Guardians)

Do you use a wheelchair?

Do you use a cane?

Do you use a walker?

Can you walk up and down a set of eight bus steps with assistance??

Can you walk the length of a football field without assistance?

Do you have a history of seizures (please explain)?

Do you have problems with motion sickeness (please explain)?

Do you have a history of sinus or ear problems (please explain)?

Do you have breathing problems (please explain)?

Do you use bottled oxygen at any time (please explain)?

Do you use a home nebulizer machine?

Do you wear or have a heart pacemaker implanted?

Are you deaf or hard of hearing?

Have you been diagnosed with dementia or Alzheimer's disease?

Have you been diagnosed with diabetes? If so, how is it controlled?

Do you have urostomy, foley or a colostomy bag?

Are you legally blind?

Are you color blind?

What medications are you taking? (name, dosage and how often you take it)

Are you allergic to any drugs or foods? Describe in detail.

How did you hear about Honor Flight?