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Patient Request Form

PLEASE INITIAL THE FOLLOWING:
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.
Patients must arrange their own ground transportation to/from the airport and hotel/lodging (if needed).
Baggage requirements: Flexible bags are recommended. Baggage must be less than 50 lbs.
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.
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
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.
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.