Flight Request Form

Fill out as much as you can & we will be in touch!

Please submit only one form and refrain from sending multiple.

Parent 1 Full Name

Parent 2 Full Name

Child's Full Name

Purpose of Flight(s)

Parent / Child's Home Address

Child's Date of Birth

Recent Photo of Your Child ( Optional )

Letter of Medical Necessity* - The letter (on the provider's letterhead) must be signed by a treating physician and state: (1) the medical reason(s) for a private jet flight, i.e., why an airline flight is not a safe or reasonable option, and (2) the child passenger is safe to fly on a jet pressurized to a cabin altitude of 6,000-8,000 feet above sea level for the duration of the flight. Contact [email protected] for more information.

Departure / Arrival Locations

Total Weight of Passengers (lbs)

Phone

Emergency Contact

Will other family members need to travel with you?

Dates of Travel

Preferred times to depart and arrive

Appointment days/times

Estimated release date from hospital

Will additional treatment/travel be needed?

Does one or more of the passengers speak English?

Do all adult passengers (18 years and older) have a current REAL ID Act-compliant identification or U.S. Passport?

Please provide any other health-related information that supports your request for a private flight and any other information pertinent to your child being able to fly on a private flight.

Treating Doctor's Name

Treating Doctor's Email

Treating Doctor's Phone Number

Name of Medical Facility where treatment will be received

Social Worker's Name

Social Worker's Email

Social Worker's Phone

Medical equipment to be brought on board

Medical Equipment Photos (If available)

Accommodations at destination

Ground transportation at destination

Have you checked to see if insurance will pay for flight? Medicaid?

Are you working with any other organizations? If so, which ones?

Will you still travel if we are not able to fill the flight both ways?

What is the last day/date we can notify you about a flight prior to you using the back up plan?

List of potential local organizations that could help fund a flight if needed

How did you hear about AeroAngel?