Company Information

Company Name

Contact Name

Contact Email

Contact Phone Number

Expedition Participant Information

First Name

Last Name

Date of Birth

Occupation
Professional Truck DriverTransportation Industry ProfessionalOther

Are you a military veteran?
YesNo

Military Branch
Air ForceArmyArmy ReserveCoast GuardMarine CorpsNavyNational GuardSpace ForceROTCN/A

Highest Rank Achieved

Are you a Vietnam veteran?
YesNo

Where in Vietnam or what surrounding areas were you in, mainly?

Tell us about yourself:

Please describe what this experience would mean to you.

Rate Your Fitness Level:
This trip requires extensive walking, stairs, some hiking, kayaking, and two 24-hour long international flights to and from Las Vegas.
Select oneI require a wheelchair/walker/cane/otherI can walk up to 1 mile with rest and breaksI can walk 1-2 miles if I pace myselfNo issues with extended walking or many stairsI can walk around in a city for 4-5 hoursZero issue with strenuous upper and lower body activities

Are you prepared to travel nonstop for 20-30 hours one way between the US and Vietnam twice within a 10-day period?
YesNo

I attest to having no medical condition that can be aggravated by traveling nonstop for 20-30 hours.
YesNo

Detail any injuries, limitations, or medical conditions:

Rate your mental health:
1 - At Peace2345678910 - At Risk

Do you have a current passport?
YesNo

Please enter the expiration date of your passport.

I agree to purchase my own e-visa ($25) prior to the trip*.
*Scholarships have been made available to cover this cost-based on need.
YesNo

Are you able to travel to Vietnam November 4-12, 2023?
YesNo

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