Brookshire’s World War II Heroes Flight – Veteran Application

Brookshire Grocery Company (“Brookshire’s”) wishes to recognize American World War II veterans for their service, sacrifices, and achievements by flying them to Washington, DC to see THEIR memorial at no cost. In order for Brookshire’s to achieve this goal, guardians fly with the veterans on every flight providing assistance and helping veterans have a safe, memorable and rewarding experience. For what you and your comrades have given to us, please consider this a small token of appreciation from all of us at Brookshire’s. For further information, please contact us @ 903-534-3112.

1. Personal Information * required

Phone *(at least one is required):

2. Service History * required

3. Alternate Contact (son, daughter, etc) * required


Emergency Contact Information (someone available on the days you travel)

Phone *(at least one is required):



PLEASE FILL OUT THE MEDICAL QUESTIONNAIRE BELOW:
Medical information provided will not disqualify you. It permits us to assess the support we need during the trip. Info is for BROOKSHIRE’S WWII HEROES FLIGHT and medical personnel ONLY.

4. Medical Information

Do you use mobility equipment?
Do you take medication?
Do you have any drug allergies?
Do you have a history of seizure?
Do you have problems with motion sickness (sea or air)?
Do you have any breathing problems?
Do you use a home nebulizer machine?
Do you take medication for or have a history of mild, moderate, or severe dementia?
Do you use oxygen at any time?
Do you have a problem walking the length of a football field without assistance?
Do you have a history of open head injuries, sinus problems, or ear problems?
Do you have a ureterostomy or colostomy bag?

ONLINE APPLICANTS WILL BE REQUIRED TO SIGN PRIOR TO FLIGHT DATE IN ACKNOWLEGEMENT OF AND AGREEMENT TO THE FOLLOWING:

1. Photographic and video equipment may be used to memorialize and document Brookshire’s WWII Heroes Flight trips and events. Consequently your image may appear in a public forum, such as the media or a website, to acknowledge, promote or advance the work of the event. I hereby release the photographer and Brookshire Grocery Company from all claims and liability relating to said photographs. I hereby give permission for my images captured during Heroes Flight activities through video, photo, or other media, to be used solely for the purposes of Brookshire Grocery Company 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 veteran and I understand that Brookshire Grocery Company does NOT provide medical care. I understand that I accept all risks associated with travel and other Heroes Flight activities and will not hold Brookshire Grocery Company responsible for any injuries incurred by me while participating in the Heroes Flight program.

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