Flight Application Donation

FOOTPRINTS in the SKY requests a $35 tax deductible fee from all patients seeking a flight with us. A significant amount of time and effort goes into coordinating your transportation with your medical flight needs.


Please Note: Receipt of this fee confirms your need and desire to retain the services of FOOTPRINTS in the SKY.


100% of this tax deductible fee will be applied as a donation.


Click Here to complete the Flight Application Donation



Flight Application

    First Name

    Last Name

    Primary Phone Number

    Secondary Phone Number

    Email

    Address

    City

    State

    Zipcode

    Date of Birth


    Patient Representative (if applicable)

    Relationship to Patient

    Representative's Phone Number


    Attending Physician

    Phone


    Flight Request Information
    Medical Appointment Date

    Target Flight Date (based on availability)

    Return Flight Date (based on availability)

    Destinations
    Departure City

    Arrival City

    Return Flight
    Departure City

    Arrival City

    Reason for Flight

    Special Medical Equipment


    Treatment Facility


    Passengers (subject to capacity)
    Number of Passengers

    Passenger #1 Name (patient)

    Passenger #1 Age

    Passenger #2

    Passenger #3

    Passenger #4


    Notes/Comments

    IMPORTANT: PLEASE NOTE
    Due to the length of time normally required to obtain an authorization from your doctor for your flight, this application will need to be in our office at least 10 days prior to your flight request date. Exceptions to this will be considered on a case by case basis.

    I have read the Terms and Conditions and understand my responsibilities regarding this free flight. I realize that the Pilot(s) retain the right to cancel due to changing weather or other circumstances. Also, it is my responsibility to have a realistic back-up plan. I must also be prepared for unforeseen delays and have the resources to deal with such situations.

    Read Terms and Conditions Here

    I have read the Terms and Conditions