Please fill out the form below with as much detail about your child’s medical condition and the dates you require your flight. We will contact you within 24 hours, if not sooner. For urgent requests, please call (303) 817-7355.

Parent 1 Full Name *

Parent 2 Ful Name

Child's Full Name *

Purpose of Flight(s)

Parent / Child's Home Address *

Child's Date of Birth *

Recent Photo of Your Child ( Optional )

Letter of Medical Necessity* - The letter (on the provider's letterhead) must be signed by a treating physician and state: (1) the medical reason(s) for a private jet flight, i.e., why an airline flight is not a safe or reasonable option, and (2) the child passenger is safe to fly on a jet pressurized to a cabin altitude of 6,000-8,000 feet above sea level for the duration of the flight. Contact [email protected] for more information.

Medical Letter

Departure / Arrival Locations *

Total Weight of Passengers (lbs) *

Email *

Phone *

Emergency Contact *

Will other family members need to travel with you? *

Dates of Travel *

Preferred times to depart and arrive *

Appointment days/times *

Estimated release date from hospital *

Will additional treatment/travel be needed?

Does one or more of the passengers speak English? *

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 *

Social Worker's Name *

Social Worker's Email *

Social Worker's Phone *

Medical equipment to be brought on board

Medical Equipment Photos (If available)

Accommodations at destination

Ground transportation at destination

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

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

Will you still travel if we are not able to fill the flight both ways?

What is the last day/date we can notify you about a flight prior to you using the back up plan? *

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

How did you hear about AeroAngel? *