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Patient Request Form
Patient's Name
*
First
Last
Age
*
Sex
*
Weight
*
Patient Phone Number
*
Alternate Number
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Caregiver Name: (if applicable)
First
Last
Caregiver Age
Caregiver Sex
Caregiver Weight
Name of Your Church: (optional)
Pastor’s Name
Church Phone Number
Pastor’s Cell (optional)
Please rate your ability to travel (scale 1-10; 1-can easily travel / 10-have difficulty traveling)
*
NATURE OF NEED: (Check the need(s) that apply)
*
Time-Critical (Need for travel in the next 24 hours or as soon as possible)
Financial Need (individual and family unable to provide finances for trip)
Compassion (physically unable to travel by any other means including airlines)
Lack of local/nearby commercial service
Low Immunity System; not safe to be in presence of large groups of people
What City Are You Traveling From?
*
Where Do You Need to Go?
*
First Appointment Date and Time:
*
Date
Time
Requested Date of Travel:
*
Return Flight Requested?
*
Yes
No
How Often Will You Need Flights:
*
Last Appointment Date and Time:
*
Date
Time
Requested Return Date:
*
PLEASE INITIAL THE FOLLOWING:
Initials
*
Patients may carry their own oxygen in an FFA-approved container but PFC volunteers are not able to provide any medical service before, during, or after the flight. A letter from a doctor indicating a list of any special equipment needed is required. We cannot accept an application if the person requires any life support equipment, incubator, etc. although wheelchair may be accepted.
Initials
*
Patients must arrange their own ground transportation to/from the airport and hotel/lodging (if needed).
Initials
*
Baggage requirements: Flexible bags are recommended. Baggage must be less than 50 lbs.
Initials
*
Patients should have back-up transportation in the event of a last-minute cancellation of our flight for reasons outside of Pilot for Christ’s control such as inclement weather, sickness, or FAA restrictions.
Initials
*
Patients must be physically fit to travel in a non-pressurized aircraft up to 11,000 feet MSL without access to lavatory facilities for the duration of the flight. Patient is able to get into and out of the aircraft with minimal assistance
Initials
*
Patient confirms to the best of his/her knowledge that all information submitted on this form is true and correct and accepts all terms, conditions, and limitations set forth by Pilots for Christ, Inc.
I, (patient)
*
agree to hold harmless, indemnify, and defend Pilots for Christ, Inc., Its members, directors, officers, employees, agents, and contractors along with the heirs, personal representatives, successors, and assigns of each of them from and against all liabilities, penalties, costs, losses, damages, expenses, causes of action, claims, demands, or judgments, including, without limitation, reasonable attorney's fees. I further declare that I do not need any medical assistance during this flight and understand this flight will be conducted under Part 91 of the Federal Aviation Regulations. I understand it is my sole and exclusive responsibility, as a patient and passenger, to purchase any flight or accident insurance should I desire to be insured on this fight. I also understand Pilots for Christ, Inc. is not responsible for a pilot’s currency requirements; however, I may contact the pilot prior to flight for verification. I understand that Pilots for Christ, Inc. relies upon contributions which are in part based upon public media. In order to contribute to these efforts, I grant Pilots for Christ, Inc. permission to take and use my photograph, personal information and medical information for prayer, promotion and public relations. I also give Pilots for Christ permission to use this information to speak on my behalf for any commercial airline tickets purchases and/or needs for rescheduling of flights. Any/all refunded commercial flights purchased with Pilots for Christ funds will be issued back to Pilots for Christ. In the event that any portion of this agreement is held invalid, the remaining portions shall remain in full force and effect.As evidenced by my signature below, I have read this agreement in its entirety and agree to all its terms.
Print Name (Patient)
*
Signature (Patient)
*
Clear Signature
Date Signed
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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