Miles for Kids in Need

Please fill out all information below. This form is for Miles for Kids approved organizations to submit patient flight requests. For official use only.

Requestor (non-profit organization, hospital, physician, etc)

How will fees/taxes be paid?

 Credit Card  Other 

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Minor Child Information

Gender*:  Male  Female 

Reason for requesting air transportation*

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Has required travel paperwork been completed?

 Yes  No  Pending 

Is a wheelchair needed?

 Yes  No 

Are you bringing your own?

Is the wheelchair manual or self-propelled?

Require long-distance assistance?

 Yes  No 

Require assistance to seat?

 Yes  No 

Does child require separate seat?

 Yes  No 

Will child be held in lap?

 Yes  No 

Parent Information

Gender:  Male  Female 

Guardian/Escort traveling with the child (if not the parent)

Gender:  Male  Female 

Does patient require ambassador escort?

 Yes  No 

AA Escort Coordinator

AA Ambassador Flight Information

Information about the person completing this application

IMPORTANT: Patient authorizes Mercy Medical to contact his or her physician through the information I have provided to obtain a medical clearance form showing proof of appointment:

 Yes  No