Pre-Flight Medical Form - Volunteer/Guardian

Volunteer/Guardian Name

First

Middle

Last

Volunteer/Guardian Email

Entering a valid email will allow the Western ND Honor Flight to send you an email confirmation after this form has been submitted.

This information is necessary so that we may provide you with appropriate medical support during your trip. This information is for the Honor Flight medical team only and will remain confidential. Your responses to these questions will not affect your eligibility. Please fill out this page completely. If something does not apply to you, please write N/A or NONE. Do not leave any questions blank.

List any drug allergies and what type of reaction for each individual drug?

Type NONE if none.

List any food allergies and what type of reaction for each individual food item?

Type NONE if none.

Do you use a CPAP Machine?

(you may bring this with you)

Please list other medical conditions:

*If yes to any of the above questions, a medical team member may contact you.

EMERGENCY CONTACT

Emergency Contact Name

First

Last

Relationship

Emergency Contact Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Day Phone

Emergency Contact Email

Contact Evening Phone

Contact Cell Phone

Pre-Flight – Volunteer/Guardian Medical Form

Pre-Flight Medical Form - Volunteer/Guardian

EMERGENCY CONTACT

MEDICATIONS

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