Utah Honor Flight | Veteran Registration Form

Veteran Information

First Name

Middle Name

Last Name

Nickname (if used)

Date of Birth

Gender

Male Female

Contact Information

Street Address

City

State

Zipcode

Daytime Phone

Evening Phone

Mobile Phone

Email Address

Emergency Contact

The Emergency Contact should be someone available on the day of the trip.

First Name

Last Name

Relationship

Mobile Phone

Email Address

Alternate Contact

First Name

Last Name

Relationship

Mobile Phone

Email Address

Medical Information

What is your Weight?

What is your Height?

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

Medications

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 Questions

Have you been diagnosed by a physician with a terminal illness?:

If you answered yes to the question above, please provide details.:

Have you been the recipient of a previous Honor Flight trip:

Conflicts During Your Service:

WW II (Dec. 7 1941 - 1946)

Cold War - Post WWII (1947-1950)

Korea (1950 - 1955)

Cold War - Post Korea (1956-1960)

Vietnam (1961 - May 8 1975)

Lebanon/Grenada (August 24, 1982 - July 31, 1984)

Panama (Dec 20, 1989 - Jan 31,1990)

Gulf War/War on Terrorism (Aug 2, 1990 - Present)

Other (please give dates of service above in service history)