Our Well Being

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  Unknown 

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 

Guardian/Escort traveling with the child

Second Escort

Third Escort

Does patient require ambassador escort?

 Yes  No 

AA Ambassador Flight Information

I certify that that organization submitting this request is in compliance with American Airlines Miles for Kids in Need program guidelines.

 Yes  No 

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