Inside Timeframe Exception Request Form
All Flight Request Forms and supporting documentation must be received at least 14 days prior to the requested departure date. On occasion our organization is able to accommodate Flight Requests inside the 14 day policy. To request an exception, please complete the form below. Each request will be reviewed internally and the Miracle Flights team will communicate any relevant next steps to you as soon as possible.
Full Name of Person Completing This Form
*
Email
*
example@example.com
Cell Phone Number
*
Patient Full Name
*
Patient Date of Birth
*
/
Month
/
Day
Year
Relationship to Patient
*
Parent/Legal Guardian
Caregiver
Immediate Family Member
Has Miracle Flights provided flights for you in the past?
*
Yes
No
Requested Departure Date
*
-
Month
-
Day
Year
Date
Medical Appointment Date
*
-
Month
-
Day
Year
Date
Requested Return Date
*
-
Month
-
Day
Year
Date
Departure Airport
*
3 Letter Code
Arrival Airport
*
3 Letter Code
Total Number of Traveling Passengers
*
Child Patient + Parent/Legal Guardians/Family Members
Please describe why you were unable to submit your flight request form on time.
*
Request Form Terms
*
I understand that submitting this form does not automatically grant approval of my request. I understand that Miracle Flights will review each form submitted and a response will be emailed to me. It is my sole responsibility to receive that email and follow the instructions carefully. I understand that Miracle Flights has the authority to cancel my flight request at any time due to any pricing and/or availability issues that may occur when coordinating travel.
Signature
*
Signer Name
First Name
Last Name
Signer Relationship to Patient
Self (I am 18 or over)
Parent/Guardian (Patient is 17 or under)
Submit
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