Flight Application Step 1 of 6 16% Your InformationFor the fields below, please information about yourself, not the passenger (unless you are the passenger).Your Name(Required) First Last Your Email(Required) Phone(Required)How did you hear about us? Doctor Website Facebook Twitter Instagram Tik Tok Church Newsletter Friend Other Passenger InformationFor the fields below, please enter information about the passenger who would be flying with us.Your Relationship to the Passenger(Required) Passenger Name(Required) First Last Passenger Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Passenger Contact Phone(Required)Passenger Gender(Required)Prefer Not to AnswerMaleFemalePassenger Birth Day(Required) MM slash DD slash YYYY Passenger Height(Required) Please enter in feet and inches. (ex. 6'2").Passenger Weight(Required) Please enter the passenger's weight in US pounds. Pilots require this information in order to calculate fuel for the flight.Ability to Move(Required) Normal - Can walk or climb without assistance Limited - Can walk and climb with assistance Restricted - Can walk with assistance but not climb Wheelchair - Must be lifted into aircraft, cannot walk but can sit upright in aircraft seat Recumbent - Must be lifted into aircraft, cannot sit upright Stretcher - Must be lifted into aircraft on stretcher, cannot sit upright Choose the highest level of mobility which is safe for this person. Emergency ContactsAt least one emergency contact is required.Emergency Contact 1(Required) First Last Relationship(Required) Phone(Required)Email(Required) Emergency Contact 2 First Last Relationship PhoneEmail Flight InformationDeparture Date(Required) MM slash DD slash YYYY Return Date MM slash DD slash YYYY Preferred Departure Airport Preferred Destination Airport Departure State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDestination State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingIn order to quality, you must have a departure location or destination within Michigan, Wisconsin, Indiana, Illinois, or OhioIn order to quality, you must have a medical need for long distance transportation East of the Rocky Mountains. Flight Companion InformationWings of Mercy requires that you have a companion fly with you.Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Flight Companion Height(Required) Please enter in feet and inches. (Ex. 6'2")Flight Companion Weight(Required) Please enter the flight companion's weight in US pounds. Pilots require this information in order to calculate fuel for the flight. Form CompletionSignature(Required)By signing below, I affirm that I have read all forms and am aware of restrictions and limitations of a Wings of Mercy flights. I also understand that Wings of Mercy may use photos from flight, and I may call or write to request to opt out of photos.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
