About PALS
Our People
Financials
Latest News
Shop PALS
Contact Us
You Can Help
Donate
Planned Giving
Open Skies Campaign
Events
Run with PALS
Sponsors & Partners
Volunteer with PALS
Contact Us
Menu
About PALS
Our People
Financials
Latest News
Shop PALS
Contact Us
You Can Help
Donate
Planned Giving
Open Skies Campaign
Events
Run with PALS
Sponsors & Partners
Volunteer with PALS
Contact Us
Twitter
Facebook
Instagram
Linkedin
Youtube
Passengers
Request a Flight
Passenger Stories
PALS for Patriots
FAQ
Resources
Patient Forms
Pilots
Application
Flight Forms
Training & Resources
Pilot Login
Menu
Passengers
Request a Flight
Passenger Stories
PALS for Patriots
FAQ
Resources
Patient Forms
Pilots
Application
Flight Forms
Training & Resources
Pilot Login
Passengers
Request a Flight
Passenger Stories
PALS for Patriots
FAQ
Resources
Patient Forms
For Pilots
Application
Flight Forms
Training & Resources
Pilot Login
About PALS
Our People
Financials
Shop PALS
Latest News
Contact Us
You Can Help
Donate
Planned Giving
Open Skies Campaign
Events
Run with PALS
Sponsors & Partners
Volunteer with PALS
New Patient Request
Existing Patient Request
Menu
Passengers
Request a Flight
Passenger Stories
PALS for Patriots
FAQ
Resources
Patient Forms
For Pilots
Application
Flight Forms
Training & Resources
Pilot Login
About PALS
Our People
Financials
Shop PALS
Latest News
Contact Us
You Can Help
Donate
Planned Giving
Open Skies Campaign
Events
Run with PALS
Sponsors & Partners
Volunteer with PALS
New Patient Request
Existing Patient Request
Donate
Request a free flight
Step
1
of
7
- General Contact Info
0%
Legal Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
CAPTCHA
Has the patient flown with us before?
(Required)
Yes
No
Who is requesting the flight?
(Required)
Patient
Parent or Guardian
Friend or Relative
Social Worker
Physician or Physician's Office Staff
Other
Let's just grab some information about the patient
Legal Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Patient Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Height (feet)
Height (inches)
Weight (lbs)
Date of Birth
(Required)
Month
Day
Year
Is the patient traveling with a companion?
(Required)
Yes
No
Who should we contact regarding this flight?
(Required)
Patient
Companion
Ok, please provide some information about the companion
Companion contact information
(Required)
First Name
Last Name
Relationship to the patient
(Required)
Spouse
Parent
Grandparent
Caregiver
Friend
Other
Phone
Email
(Required)
Companion Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Height (feet)
Height (inches)
Weight (lbs)
Date of Birth
(Required)
Month
Day
Year
Appointment Date
MM slash DD slash YYYY
Appointment Time
Hour
HR
12
1
2
3
4
5
6
7
8
9
10
11
Minute
00
15
30
45
AM/PM
AM
PM
Are there any special requirements? (Walker, stroller, oxygen, etc)
Yes
No
Can you tell us what those are?
Just need some quick info about your physician(s) and treatment facility.
NOTE: We will require a medical release from your physician in order to travel with us
Physician providing medical release
NOTE: Must have visited within the last 6 months. It's ok if you don't have this handy, we can gather this information when we speak with you.
Treating Physician
First
Last
Phone
Email
Fax
Releasing Physician
First
Last
Phone
Email
Fax
Can you tell us about the patient treatment facility?
Treatment Facility Name
Is the patient active duty or a retired veteran?
Yes
No
Don't know
Great, do you know which branch of the military?
Air Force
Army
Marines
Navy
Has the patient or companion ever been convicted of a crime?
(Required)
Yes
No
Don't know
Ok no problem, please tell us a bit more about the details of the crime(s)
Does the patient or companion have a history of behavioral issues and/or specific behavioral issues that could distract the pilot, including seizures?
Yes
No
Don't know
Can you explain more?
Δ