"*" indicates required fields Step 1 of 7 14% Veteran ApplicationRichland County Honor Trip is provided to each veteran at no cost. Top priority is given to our WWII veterans. A guardian will be provided to assist you on this three-day bus tour to Washington, D.C. This application places you on our list only. Seats on the bus are filled on a first-come, first, served basis. We will contact you regarding your application. We do not accept donations from the veterans participating in the trip prior to their trip. Name*As it appears on your ID First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Ohio County*Please ChooseRichlandAshlandKnoxAge*Gender*MaleFemaleJacket Size*SmallMediumLargeX-LargeXX-LargeXXX-Large Spouses InformationName First Last PhoneEmergency ContactSon, daughter, etc. This is the contact for emergencies when you are on the trip. Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PhoneEmail Relationship Traveling with another Veteran?If you would like to travel with another veteran, please provide their name below. Name First Last Military ServiceIn what conflict did you serve?*WWIIKorean WarVietnamOtherBranch of Service* Highest Rank at end of service* Dates of Service Military ActivityYears of Service, Decorations, War and Items of Special Interest. Medical InformationThe information provided will not disqualify you. It permits us to assess the support we need during the trip. Information is for Seneca County Honor Bus personnel only. Please note that you will be required to climb up and down short flights of steps to enter and exit the bus. Your physician must be aware of your planned participation of this three day trip. I have motion sickness* Yes No Please Explain I have breathing problems* Yes No Please Explain I use a home nebulizer machine or CPAP* Yes No Please Explain I use Oxygen* Yes No Please Explain Diagnosed Alzheimer's?* Yes No Please Explain I use a colostomy or urostomy bag* Yes No Please Explain I am a diabetic* Yes No Please Explain I have a pacemaker* Yes No Please Explain Previous heart conditions* Yes No Please Explain I use a cane, walker, wheelchair* Yes No Please Explain History of Epilepsy or Seizures* Yes No Please Explain Can you walk the length of a football field?* Yes No Please Explain Do you sleepwalk?* Yes No Please Explain Do you wear depends or similar products?* Yes No Please Explain Other Medical Issues* Yes No Please Explain Weight*In lbsPlease list any special diet needs Additional Medical InformationDrug and/or Food AllergiesPlease list any drug and/or food allergies you may haveAllergy Add RemoveI have checked with my Dr regarding this trip & time away* Yes No Additional Medical HistoryAny other significant medical history we should know, including operations in the last two years? Medication & Pharmacy InformationYour Pharmacy's Name Your Pharmacy's Phone NumberMedicationsMedication NameHow OftenDose & Time of DayRX # Add Remove Review & Submit ApplicationAs photographic and video equipment are frequently used to memorialize and document Richland County Honor Trip and events, my image may appear in a public forum, such as the media or website, to acknowledge, promote or advance the work of the Richland County Honor Trip program. I hereby release the photographer and Richland Country Honor Trip from all claims and liability relating to said photographs. I hereby give permission for my images captured during Richland Country Honor Trip activities through video, photo, or other media, to med used solely for the purpose of Richland County Honor Trip promotional materials and publications, and wave any rights or compensation or ownership thereto. I understand and acknowledge that medical insurance is the responsibility of me, the veteran, and that Richland County Honor Trip does not provide medical care. I accept all risks associated with travel and other Richland County Honor Trip activities and will not hold Richland County Honor Trip responsible for any injuries incurred by me while participating in the Richland County Honor Trip. I acknowledge that I have reviewed this application and that the information provided is true and accurate, Further, the undersigned does release and hold harmless Richland County Honor Trip, organization sponsors, committee members, agents successors and assigns from any and all actions, claims or damages for any personal injuries or property damages which may occur in the course of or during this trip or any of its activities. I also attest that I have never been convicted of a felony nor under investigation for a felony offense. Your Name* Todays Date* MM slash DD slash YYYY This application will be sent to: AMVETS Post #26 1100 Fourth St. Mansfield, OH 44906 ATTN: Richland County Veterans Honor Bus 419-565-3769
