*Name

*Email Address

*Purpose of Flight(s)

*Message

*Departure / Arrival Locations

*Dates of Travel

*Phone

Emergency Contact Information

Will other family members need to travel with you?

Preferred times to depart and arrive

Will additional treatment/travel be needed?

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

Special medical equipment to be brought on board

Medical Equipment Photos (If available)

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

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

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

How did you hear about us?