Gender-Affirming Care Passenger Request

Air Travel Request for Gender-Affirming Care
Airtable Flight Request #1
Airtable Flight Request #2
Important Notes:

We are a 501c3 non-profit that depends on donations to support our work. Currently, we do not make a "need-based" evaluation for whether to support each person's request. However, we respectfully ask that you not submit a travel request if paying for your travel would not create a financial hardship for you.

To arrange travel, we must confirm with your healthcare provider or case worker that you have care scheduled. If your provider requires that you have travel arranged to schedule you, you may proceed with this form with your expected travel dates.

**** Elevated Access will be offline from 11/9-11/11 for Veterans Day weekend. We will be unavailable for these days and will resume normal operation 11/12****
Are you over 18? If not, a parent or guardian must complete this form.*

Yes
What's it like flying on a small airplane?
Backup Plan*
There is no guarantee that we will be able to arrange travel. Last minute issues may cause a flight to be cancelled. It is important that you have a backup plan for your travel. Please identify your backup plan if a flight cannot be arranged or is cancelled.
We only provide the air transportation component of your journey and only once you have your appointment confirmed. In order to request a flight, you must already have plans or arrangements for the following.*

I already have my appointment scheduled.I already have ground transportation planned or arranged for departure and destination.I already have lodging planned or arranged.
Name*

First NameLast Name
Pronouns*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred method of contact*

EmailPhoneSMS textSignal message

Provider Information

Please enter information for us to contact your provider in order to confirm that you have care scheduled or that will be scheduled.
Provider Name*
Name of the clinic or facility
Provider Contact*

First NameLast Name
Provider Phone Number*
Please enter a valid phone number.
Provider Email*
We will send this form for approval to this email address. Make sure your provider is aware and looking for it.
Name on file with the provider if it is different than what you put on the previous page

First NameLast Name

Travel Schedule
Your home Zip code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Destination Zip code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date and time do you need to arrive?*

MonthDayYear
Date
Hour MinutesAM/PM Option
What date and time will you be ready to return?*

MonthDayYear
Date
Hour MinutesAM/PM Option
How many times will you need to make this trip?*
How often will you need to make this trip if more than once?
Passenger Information

All aircraft are limited by the maximum weight that they can carry and sometimes have specific requirements on how they can be loaded. We need your accurate weight to ensure a safe seating configuration for the flight. Please limit baggage to 50 pounds or less. If you have a need to take more, please describe that in the Notes.
Your weight*
Do you need to travel with a companion?*

NoYes
Companion Name

First NameLast Name
Companion Age
Companion Pronouns
Companion Weight
Do you (and/or your companion) have any mobility limitations or other needs that may impact your ability to travel safely with one of our volunteer pilots or may require additional support?*

YesNo
If yes, please share any information you're able.
Is there anything else we need to know?
Information for Airlines

In some situations, we may offer to provide airline tickets. If you hope to have that option available, please complete the following information.
Passenger 1 Name (as it appears on the ID you will be traveling with)

First NameLast Name
Passenger 1 Birthdate (as it appears on the ID you will be traveling with)

MonthDayYear
Date
Passenger 1 Gender (as it appears on the ID you will be traveling with)
Passenger 2 Name (as it appears on the ID they will be traveling with)

First NameLast Name
Passenger 2 Birthdate (as it appears on the ID they will be traveling with)

MonthDayYear
Date
Passenger 2 Gender (as it appears on the ID they will be traveling with)
Please note that TSA policy states that passengers under 18 are not required to travel with an ID.
If you are traveling by airline, will you need any special services like wheelchair assistance?

YesNo
If you answered 'yes' to the last question, please let us know what services you will need so we can include them when booking.
We would like to ask if our passengers are willing to participate in a survey for the purpose of quality improvement. Do you feel comfortable and safe being contacted by Elevated Access via email after your flight?*

YesNo
Should be Empty:

Air Travel Request for Gender-Affirming Care

Important Notes:

What's it like flying on a small airplane?

Provider Information

Travel Schedule

Passenger Information

Information for Airlines