Child Flight Request Application [Rob July 2023 Edit]

Information needed to proceed with application:
- Scheduled Medical Appointment and Release Date(s) -- Your treatment site must be able to verify your medical appointment date(s)
- Requested Flight Dates (within 3 days of medical appointment and release dates)
- Passenger Information (full names, date of birth, address)
- Birth Certificate For Traveling Passengers Under the Age of 18 PDF/JPG/PNG -- Upload required
- Household Income and/or Government Assistance Certification PDF/JPG/PNG -- Upload required. First two pages of latest 1040 tax return documents or proof of current government assistance program are required for all applicants (dated within the last 90 days). With prior approval via Financial Hardship Exception Form, SSI/SSDI statements and/or paystubs may be submitted in lieu of 1040 tax documents for all income earners responsible for the child patient in the household.
Make sure you have the above information ready BEFORE moving forward with your application. Total time to complete is less than 15 minutes.

If you are an adult patient, or if your departure date is less than 14 days away, or if you are requesting travel from outside the US - DO NOT PROCEED - as you will be denied services at this time.
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Flight Request Details
Our dedicated Flight Department coordinates hundreds of flights each month for families across the U.S. The information provided below will help our team find the best flights based on your departure/arrival city and appointment day/time. Please include alternative airports (if applicable) to allow us to serve you in the most time/cost effective way possible.

All departure and return flight dates must be booked within 3 days of the scheduled medical appointment date and treatment site release date.
Child Patient Verification - Will the patient be 17 years old or younger at the time of the medical appointment?

Yes - Miracle Flights will provide flights to a qualifying child patient (age 17 and under at the time of medical appointment) and up to two additional parents/legal guardians/family members (up to 3 total passengers).No
We're Sorry

Unfortunately we cannot help at this time. We only provide flights for pediatric patients (17 and under). If your child was a recipient of our services in the past and they are now 18 or over or if you think you have received this message in error, please email apphelp@miracleflights.org.
If approved, will this be your first time using Miracle Flights?*

YesNo
Welcome Back! We're excited to help you and your family again.
Welcome to The Miracle Flights Family!
Is your requested departure date at least 14 days away?*

YesNo
STOP - READ CAREFULLY

You've indicated that your requested departure date is less than 14 days away. If you'd like to apply for an Inside Timeframe Exception Request please urgently follow the steps below. Once submitted, our team will review your request and let you know if we're able to accomodate.

Next steps:

1) Submit online Inside Timeframe Exception Request Form Here or by clicking this link: https://hipaa.jotform.com/build/232016425489154

2) Patiently wait for Miracle Flights team to review and email you a reply.

3) If exception request is granted, Miracle Flights Team will email you a new application.
What Type of Travel Is This?*

Roundtrip Flight (Departure and Return Flight)One-Way Flight (Departure Flight Only)
Scheduled Medical Appointment Date*

MonthDayYear
Will be verified by treatment site
IT - Scheduled Medical Appointment Date*

MonthDayYear
Will be verified by treatment site
Departure Date*

MonthDayYear
Within 3 days before first scheduled appointment
IT - Departure Date

MonthDayYear
Within 3 days before first scheduled appointment
Airport of Origin (Flying From)*
Enter 3 letter airport code
Alternate Airport of Origin (Flying From)
Enter 3 letter airport code
Destination Airport (Flying To)*
Enter 3 letter airport code
Alternate Destination Airport (Flying To)
Enter 3 letter airport code
Return Date*

MonthDayYear
Within 3 days following final appointment/release date
IT - Return Date*

MonthDayYear
Within 3 days following final appointment/release date
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Child Patient Waiver of Liability

To be completed by parent/legal guardian of child patient (17 and under)
Child Patient Name (as it appears on government issued identification)*
In consideration of their providing financial assistance for air travel or items or supplies at no cost and solely for my benefit, I, the undersigned, do hereby release the nonprofit Miracle Flights and commercial airlines fully and without reservation from any and all claims whatsoever of culpability, responsibility, fault and liability for any inadvertent and/or accidental occurrence which may result in personal injury or property damage or other effect, during all times that I am a passenger in the act of boarding, while aboard, or in the act of deplaning an aircraft provided by said Miracle Flights and commercial airlines:
Waive Right to Pursue Legal Action*

Furthermore, I do herewith unequivocally waive and deny, for myself and all my assigns, any and all rights to pursue any action against said Miracle Flights for any action or inaction executed by them in good faith.
Consent for Medical Treatment*

I acknowledge and confirm that both parents and/or legal guardians consent and approve of the medical treatment that the child patient is receiving as listed in this Flight Request Application.
Consent to Receive Emails and SMS Messages*

I agree to receive both automated emails and SMS messages from Miracle Flights to the email and phone numbers listed on this application. Message + data rates may apply. Reply STOP or click UNSUBSCRIBE to remove yourself from automated messages.
Photo/Video Release*

I AGREE and hereby authorize Miracle Flights and its partners, sponsors, and affiliates to use my name, likeness, photographs, reproductions, videos, recordings, or endorsements of/by me and/or my child for publicity, social media, and/or any other related Miracle Flights marketing purposes.I DO NOT authorize Miracle Flights and its partners, sponsors, and affiliates to use my name, likeness, photographs, reproductions, videos, recordings, or endorsements of/by me and/or my child for publicity, social media, and/or any other related Miracle Flights marketing purposes.
Signature (if minor, by parent/guardian)*

Clear
Signer Name*

First NameLast Name
Relationship to Patient*

Parent/Legal Guardian (Patient is 17 or under)
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Passenger 2 - Airline Ticket Required Information

Please use exact names as they appear on government identification. If patient is 17 or under, PASSENGER 2 MUST BE THE TRAVELING PATIENT'S PARENT OR LEGAL GUARDIAN AS DISPLAYED ON THE PATIENT'S BIRTH CERTIFICATE OR OTHER LEGAL DOCUMENTATION. Please confirm all details are ACCURATE as this information will be used to book your flight itinerary.
Passenger 2 - First Name*
Passenger 2 - Middle Name
Passenger 2 - Last Name*
Passenger 2 - Relationship to Patient*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Passenger 2 - Cell Phone*
Passenger 2 - Email*
example@example.com
Passenger 2 - Address is the same as the patient?*

YesNo
Passenger 2 - Street Address*
Passenger 2 - City*
Passenger 2 - State*
Passenger 2 - Postal Code*
Passenger 2 - Country*
Passenger 2 Waiver of Responsibility*

Parent/Guardian, for Patient 17 & Under (person filling out this form, present and can sign now)
Page 8 of 15

Passenger 2 - Waiver of Liability

To be completed by accompanying passenger (18 and over)
Passenger Name (as it appears on government issued identification)*
In consideration of their providing financial assistance for air travel or items or supplies at no cost and solely for my benefit, I, the undersigned, do hereby release the nonprofit Miracle Flights and commercial airlines fully and without reservation from any and all claims whatsoever of culpability, responsibility, fault and liability for any inadvertent and/or accidental occurrence which may result in personal injury or property damage or other effect, during all times that I am a passenger in the act of boarding, while aboard, or in the act of deplaning an aircraft provided by said Miracle Flights and commercial airlines:
Waive Right to Pursue Legal Action*

Furthermore, I do herewith unequivocally waive and deny, for myself and all my assigns, any and all rights to pursue any action against said Miracle Flights for any action or inaction executed by them in good faith.
Photo/Video Release*

I AGREE and hereby authorize Miracle Flights and its partners, sponsors, and affiliates to use my name, likeness, photographs, reproductions, videos, recordings, or endorsements of/by me and/or my child for publicity, social media, and/or any other related Miracle Flights marketing purposes.I DO NOT authorize Miracle Flights and its partners, sponsors, and affiliates to use my name, likeness, photographs, reproductions, videos, recordings, or endorsements of/by me and/or my child for publicity, social media, and/or any other related Miracle Flights marketing purposes.
Signature (if minor, by parent/guardian)*

Clear
Signer Name*

First NameLast Name
Relationship to Passenger 2*

Self (I am 18 or over and signing for myself)
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Will patient require a third passenger?*

YesNo
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Passenger 3 - Airline Ticket Required Information

Please use exact names as they appear on government identification. Please confirm all details are ACCURATE as this information will be used to book your flight itinerary.
Passenger 3 - First Name*
Passenger 3 - Middle Name
Passenger 3 - Last Name*
Passenger 3 - Relationship to Patient*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Passenger 3 - Email*
example@example.com
Passenger 3 - Cell Phone*
Is Passenger 3 returning on a different date than Patient/Passenger 1?*

YesNo
Explain why Passenger 3 is requesting a different return date than Patient/Passenger 1*
Passenger 3 Return Date*

MonthDayYear
Date
Passenger 3 - Address is the same as the patient?*

YesNo
Passenger 3 - Street Address*
Passenger 3 - City*
Passenger 3 - State*
Passenger 3 - Postal Code*
Passenger 3 - Country*
Passenger 3 Waiver of Responsibility*

Child passenger (parent will sign now for minor)Adult passenger (person filling out this form, present and can sign now)
Page 11 of 15

Passenger 3 - Waiver of Liability

To be completed by accompanying passenger 3 (18 and over) or by parent/legal guardian of accompanying passenger if under 17.
Passenger Name (as it appears on government issued identification)*
In consideration of their providing financial assistance for air travel or items or supplies at no cost and solely for my benefit, I, the undersigned, do hereby release the nonprofit Miracle Flights and commercial airlines fully and without reservation from any and all claims whatsoever of culpability, responsibility, fault and liability for any inadvertent and/or accidental occurrence which may result in personal injury or property damage or other effect, during all times that I am a passenger in the act of boarding, while aboard, or in the act of deplaning an aircraft provided by said Miracle Flights and commercial airlines:
Waive Right to Pursue Legal Action*

Furthermore, I do herewith unequivocally waive and deny, for myself and all my assigns, any and all rights to pursue any action against said Miracle Flights for any action or inaction executed by them in good faith.
Photo/Video Release*

I AGREE and hereby authorize Miracle Flights and its partners, sponsors, and affiliates to use my name, likeness, photographs, reproductions, videos, recordings, or endorsements of/by me and/or my child for publicity, social media, and/or any other related Miracle Flights marketing purposes.I DO NOT authorize Miracle Flights and its partners, sponsors, and affiliates to use my name, likeness, photographs, reproductions, videos, recordings, or endorsements of/by me and/or my child for publicity, social media, and/or any other related Miracle Flights marketing purposes.
Signature (if minor, by parent/guardian)*

Clear
Signer Name*

First NameLast Name
Relationship to Passenger 3*

Self (I am 18 or over and signing for myself)Parent/Guardian (Passenger 3 is 17 or under)
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Income Certification

Fraudulent statements or intentional misrepresentation shall be considered sufficient cause for denial of service.
Number of People in Household*
Child Patient Household = Child Patient + Biological Parents/Adoptive Parents/Legal Guardians living in the home + Blood siblings living in the home + Parent domestic partner living in the home. THIS NUMBER SHOULD MATCH YOUR UPLOADED IRS PROOF OF INCOME DOCUMENTS.
Annual Family/Household Income*
Gross annual income of all income earners in the household primarily responsible for the child patient (generally biological parents, adoptive parents, legal guardians, and domestic partners living in the household. Do NOT use commas. THIS NUMBER SHOULD MATCH YOUR UPLOADED IRS PROOF OF INCOME DOCUMENTS
Please describe all sources of income for the household.*
Upload proof of income - IRS 1040 and/or proof of government assistance program*

IMPORTANT -- First two pages of most recent Federal IRS Form 1040 required and any additional income documentation (ex. SSI and/or SSDI statements, child support income, etc.) If you are SELF-EMPLOYED or OWN YOUR BUSINESS, please upload your SCHEDULE 1 and any SCHEDULE C, E, or F docs. For government assistance please provide most recent recertification, redetermination, or renewal notice (dated within the last 90 days).
Cancelof
Eligibility is determined by total family income and size.*

I hereby acknowledge financial assistance for air travel will be provided to me by Miracle Flights and certify that our total gross family/household income from all sources and my family size are as indicated above.
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Flight Request Acknowledgements

Please read carefully and sign.
Cancelling or Amending Flights*

I will call Miracle Flights with any flight cancellations or changes needed to my original itinerary. I acknowledge that Miracle Flights is the only party that can cancel or amend my flights and I will not contact the airlines directly. Failure to do comply with this may put Miracle Flights and its airline relationships in jeopardy and may result in fewer flights provided to myself and others.
No Call No Show Acknowledgment*

I understand that the airline tickets are provided at no cost to me and/or my family by Miracle Flights. I will contact Miracle Flights as soon as possible to make them aware of any changes that may result in my family not being able to fly on the flights that were provided to us. Therefore, any change or cancellation not pre-approved by Miracle Flights may result in Miracle Flights losing the resources spent on your flights. In the case of a "no call no show" resulting in Miracle Flights losing resources, Miracle Flights may seek financial compensation for the travel costs and/or may deny the patient and their family future program services.
Persons of Size Acknowledgment*

According to the FAA's policy, airlines are required to establish procedures to address the issue of passengers who cannot fit in a single seat with the armrests down. The policy states that if a passenger's body extends beyond their seat and encroaches upon the adjacent seat(s), the passenger may be required to purchase an additional seat or upgrade to a class of service that provides sufficient space. Due to this policy, any individual traveling with Miracle Flights must make our flight department aware if they believe that the patient or an individual they are planning to have travel as an accompanying passenger will be affected by this policy, failure to do so may result in inability to board a scheduled flight
Consent for Medical Treatment*

I acknowledge and confirm that both parents and/or legal guardians consent and approve of the medical treatment that the child patient is receiving as listed in this Flight Request Application.
Miracle Flights reserves the right to alter policy in exceptional circumstances.

I am aware that free commercial flights arranged by Miracle Flights are charitable in nature and therefore may occur during off-peak hours and may include stopovers and/or plane changes. I also understand that flights can only be arranged according to Miracle Flights’ guidelines, as follows:
- Children Age 17 and Under: Miracle Flights will consider requests to fly the child and UP TO two parents/legal guardians/family members (up to 3 total passengers).
I am aware that any other accompanying passengers are responsible for their own flight arrangements and understand that these flight arrangements may or may not be compatible with the flight arranged for me by Miracle Flights.

Penalty for false fraudulent statement: U.S.C. Title 18, Sec. 1001 provides: “whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, or makes false, fictitious or fraudulent statements or
representation or makes or uses any false writing or documentation knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”

By signing below, I acknowledge that I have read and understand the information above.
Signature*

Clear
Name of Signer*

First NameLast Name
Signer Email*
example@example.com - We will send a confirmation of your submission to this email address.
Relationship to Patient*

Self (I am 18 or over)Parent/Legal Guardian
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Congratulations, you're almost done!

If you need to go back and review/edit anything, do it now. If the above information is accurate, you're ready to submit the application.

We look forward to serving you soon.
Page 15 of 15
Should be Empty:

Child Medical Flight Request Application

Flight Request Details

Child Patient Information

Patient Information Demographics

Child Patient Waiver of Liability

Passenger 2 - Airline Ticket Required Information

Passenger 2 - Waiver of Liability

Passenger 3 - Airline Ticket Required Information

Passenger 3 - Waiver of Liability

Income Certification

Flight Request Acknowledgements