Guardian Application Form (Page 2 of 2) in pdf

10. Please identify any physical disabilities, restrictions and/or medical conditions that would limit your ability to fulfill the

duties of a guardian. Also, please list any medications being taken and how often.

__________________________________________________________________________________________________

Medication

Taken how often?

Medication

Taken how often?

__________________________________

__________

_________________________________

__________

__________________________________

__________

_________________________________

__________

11. T-Shirt Size: (S, M, L, XL, XXL, XXXL) ______

12. Please note any medical experience you may have (e.g., EMT, CPR, Paramedics), ________________________________

__________________________________________________________________________________________________

PLEASE REVIEW CAREFULLY AND SIGN

The undersigned acknowledges and agrees that:

1. As photographic and video equipment are frequently used to memorialize and document Utah Honor Flight

trips and events, his/her image may appear in a public forum, such as the media or a website, to acknowledge,

promote or advance the work of the Utah Honor Flight program. I hereby release the photographer and Utah

Honor Flight from all claims and liability relating to said photographs. I hereby give permission for my

images captured during Utah Honor Flight activities through video, photo, or other media, to be used solely for

the purposes of Utah Honor Flight promotional material and publications, and waive any rights or

compensation or ownership thereto.

2. I further state that medical insurance is the responsibility of the Guardian and I understand that neither Utah

Honor Flight nor the provider of free private aircraft ("Flight Provider") provides medical care. I understand

that I accept all risks associated with travel and other Utah Honor Flight activities and will not hold Utah Honor

Flight, the Flight Provider, or any person appearing or quoted in any advertisement or public service

announcement for or on behalf of Utah Honor Flight responsible for any injuries incurred by me while

participating in the Utah Honor Flight program.

SIGNNATURE *: ____________________________________________________ DATE: ______ /_______ /__________

(E-mail applicants will be required to sign prior to actual trip date)

* If under 18, a parent/guardian must also sign and date below.

SIGNNATURE *: ____________________________________________________ DATE: _____ /_______ /__________

(Parent / Guardian)

Please submit this form to: Utah Honor Flight

P.O. Box 42

Richfield, UT 84701

Or FAX to: 1-435-363-3678

Utah Honor Flight Office: 435-272-0254

Email:

Guardian Application Form Page 2