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Guardian Information
First Name
Middle Name
Last Name
Nickname
(if used)
Date of Birth
Month
Jan.
Feb.
Mar.
Apr.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Gender
Male
Female
Contact Information
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Zipcode
County
Daytime Phone
Evening Phone
Mobile Phone
Email Address
Service History
Are you a Veteran?
Yes
No
Emergency Contact
The Emergency Contact should be someone available on the day of the trip.
First Name
Last Name
Relationship
Mobile Phone
Medical Information
Do you use mobility equipment?
(check all that apply)
Cane
Scooter
Walker
Wheelchair
Wheelchair (Wide)
Can you walk up & down a set of eight bus steps with assistance?
Yes
No
Do you use oxygen at any time?
Yes
No
Do you have a problem walking the length of a football field without assistance?
Yes
No
Please describe the reason (e.g. lung problems, arthritis, heart problems, etc.)
Do you have a history of open head injuries, sinus problems, or ear problems?
Yes
No
Have you been diagnosed with memory problems?
Yes
No
Do you have any condition(s) (not mentioned above) or circumstances which might limit your ability to travel with a commercial airline, or could limit your ability to physically participate in this event?
Additional Information
T-Shirt Size
S
M
L
XL
XXL
XXXL
XXXXL
Other
Are you willing to assist all veterans, and are you willing to push any wheelchair?
Yes
No
Can you lift 100 pounds?
Yes
No
Are you requesting to travel with a specific veteran, if possible?
Yes
No
Veteran's First Name
Veteran's Middle Name
Veteran's Last Name
Additional Questions
Have you been diagnosed by a physician with a terminal illness?:
Yes
No
If you answered yes to the question above, please provide details.:
Are you the spouse or significant other of the Veteran you are requesting to travel with?:
Yes
No
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