* First Name:
* Complete Middle Name:
* Last Name:
* Gender:
* Street Address:
* City:
* State:WI
* Zip:
* County:
Brown Calumet Door Florence Fond Du Lac Forest Green Lake Kewaunee Langlade Manitowoc Marinette Marquette Menominee Oconto Outagamie Shawano Waupaca Waushara Winnebago Other
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Daytime Phone Number:
Evening Phone Number:
Cell Phone Number:
E-Mail:
* Height:Under 5ft. 0in. 5ft. 0in. 5ft. 1in. 5ft. 2in. 5ft. 3in. 5ft. 4in. 5ft. 5in. 5ft. 6in. 5ft. 7in. 5ft. 8in. 5ft. 9in. 5ft. 10in. 5ft. 11in. 6ft. 0in. 6ft. 1in. 6ft. 2in. 6ft. 3in. 6ft. 4in. 6ft. 5in. 6ft. 6in. Above 6ft. 6in.
* Weight:
* Birth Date:
Month Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960
* Shirt Size:
* Branch of Service:
Eligible Veterans need to have been active duty sometime between Dec. 7, 1941 and May 7, 1975 to qualify for the Old Glory Honor Flight.
* Start Date of Service:
Month Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
* Date of Discharge:
Month Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
* Conflict served (check all that apply):
* Please tell us where you served, duties, assignments, rank? Any special accomplishments or memories?
* First Name:
* Last Name:
* Relationship:
E-Mail:
Phone Number:
Cell Phone:
* First Name:
* Last Name:
* Relationship:
E-Mail:
Phone Number:
Cell Phone:
PRELIMINARY MEDICAL INFORMATION
You are strongly encouraged to discuss this trip with your private physician.
* I currently use a wheelchair, walker, or cane:
* I am able to stand and fully support myself without assistance:
* I may need assistance walking long distances (up to the length of a football field):
* I may need assistance navigating several steps onto and off of the bus while in Washington D.C.:
* I currently use supplemental oxygen:
Please add any concerns including medical information or needs to help us make your trip as comfortable as possible:
PLEASE REVIEW CAREFULLY AND CHECK THE BOXES
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Are you requesting to fly with a fellow Service Date Qualified Veteran or Guardian escort of your choosing? If so, please list the person's full name below. Make sure they apply and list your name on their application!
I have read all the above information, understand its content and have answered the questions to the best of my ability. Signed
* First Name:
* Last Name:
Please note: You will be contacted via telephone by our staff member approximately 6 weeks prior to your flight; our phone number is 920-257-2563 so you know it’s us calling! Most veterans are on the waitlist for approximately 12 months before they get invited on a mission. Remember, if you have a family member that wants to go along as your Guardian, they need to apply online around the same time you do to be considered for the trip.
Please check "I am not a robot" and “submit” buttons below. You must check both boxes otherwise your application will not go through. Once properly submitted, you will receive a confirmation. ALL boxes with an “*” must be filled out or the application will not go through
