• Service Dog Flight Request Application

    Service Dog Flight Request Application

    For Service Dog Training and Retrieval Flights
  • Welcome to the Miracle Flights Service Dog Training and Retrieval Flight Request Application Form. Information collected will be used by our staff to review your request, and if approved, coordinate travel on your behalf. All data provided will be kept in strict confidence and only used for this purpose. 

    Before completing our application, please answer the questions below to see if you qualify for our program services. 

     

    Miracle Flights’ service dog program is exclusively for individuals traveling to retrieve and/or train a service dog. Under the ADA (Americans with Disabilities Act), a service animal is defined as a dog that has been individually trained to perform tasks directly related to a person's disability. I understand that dogs whose sole function is to provide comfort or emotional support do not qualify as service animals under the ADA definition and, therefore, are not eligible for this program.

  • Wonderful News! 

    Based on your preliminary answers, you are eligible for our program services. Click the NEXT button to complete your application.

  • Image-448
  • We're Sorry

    Unfortunately we cannot help at this time. We only provide flights for pediatric patients (age 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. 

  • We're Sorry

    Unfortunately we cannot help at this time. We only provide commercial flights. All of our passengers must be able to safely board and have the required identification to travel on commercial airplanes in accordance with guidlines set forth by airports, airlines, FAA, and the TSA.

    For air ambulance services we recommend contacting the following non-profits:

    Wings of Hope: wingsofhope.ngo

    Grace on Wings: graceonwings.org

    Air Care Alliance: aircarealliance.org

    If you think you have received this message in error, please email apphelp@miracleflights.org. 

  • We're Sorry

    Unfortunately we cannot help at this time. Miracle Flights only provides domestic U.S. flights for medical travel. We are not providing any new international flights at this time. All medical and service dog retrieval/training appointments must be scheduled prior to applying for Miracle Flights.

    Please visit us again once your have your medical appointment booked. If you think you have received this message in error, please email apphelp@miracleflights.org. 

  • We're Sorry

    Unfortunately we cannot help at this time. We require at least 14 days to process and coordinate air travel for all applicants. You can submit an exception request for flight requests inside our 14 day window HERE.

     

    If you think you have received this message in error, please email apphelp@miracleflights.org. 

  • We're Sorry

    Unfortunately we cannot help at this time. With your household size, your gross household income exceeds our eligibility requirement.

     

    If you do not have your IRS 1040 forms or your finanical situation has changed dramatically you can submit a financial hardship exception request HERE. 

     

    If you think you have received this message in error, please email apphelp@miracleflights.org. 

  • We're Sorry

    Unfortunately we cannot help at this time. Our service dog program is intended exclusively for individuals traveling to retrieve or train a service dog. According to the ADA (Americans with Disabilities Act), a service animal is a dog trained to perform tasks directly related to a person's disability.


    If you believe you need a service dog but have not yet taken the necessary steps to qualify for one, we recommend contacting organizations that specialize in service dog training and certification. For example:

    • Assistance Dogs International (ADI): www.assistancedogsinternational.org
    • Canine Companions for Independence: www.canine.org
    • The National Service Animal Registry: www.nsarco.com

    These organizations can guide you in determining if a service dog may be appropriate for your specific circumstances and disability. If so, they may be able to assist you in the process of obtaining a service dog.
     

    If you think you have received this message in error, please email apphelp@miracleflights.org. 

  • Page 1 of 15

  • Information needed to proceed with application:

    • Scheduled Service Dog Retrieval or Training 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 service dog appointment and release dates)
    • Passenger Information (full names, date of birth, address)
    • Birth Certificate For All Child Patients 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). From January 1-April 15th each year, we will also accept W-2 forms for all employment related income. 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 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. 
  • Page 2 of 15

  • 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 service dog appointment date and treatment site release date.

  • Welcome Back! We're excited to help you and your family again.

  • Welcome to The Miracle Flights Family!

  • 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 one time use code to use below, which will allow you to proceed through the rest of the application. 

  •  / /
  •  / /
  •  / /
  •  / /
  •  / /
  •  / /
  • Page 3 of 15

  • Service Dog Patient Information

    Please fill out all required fields for the service dog patient seeking service dog retrieval and/or training. The contact information listed should be the primary contact information for the family. Please confirm all details are ACCURATE as this information will be used to book your flight itinerary.
  •  / /
  • Oxygen, service dog, and wheelchair information is requested to notify the airlines.
    Miracle Flights does NOT provide oxygen, service dogs, or wheelchairs for passengers.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Page 4 of 15

  • Patient Information Demographics

  • The below information will be used in reporting demographic statistics to various foundations and government agencies. It will not be used to determine who is eligible to receive our services. In the case where a child (age 17 and under) is being transported -- the education, marital status, and employment questions apply to the parent or guardian completing this application.

  • Page 5 of 15

  • Patient Waiver of Liability

    To be completed by parent/legal guardian of child service dog patient (17 and under) or the adult service dog patient.
  • 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:

  • Clear
  • Page 6 of 15

  • Page 7 of 15

  • Passenger 2 - Airline Ticket Required Information

    Please use exact names as they appear on government identification. If service dog 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. If patient is 18 or over, PASSENGER 2 MUST BE A MEDICALLY NECESSARY COMPANION/CHAPERONE. Please confirm all details are ACCURATE as this information will be used to book your flight itinerary.
  •  - -
  • Page 8 of 15

  • Passenger 2 - Waiver of Liability

    To be completed by accompanying passenger (18 and over)
  • 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:

  • Clear
  • Page 9 of 15

  • Income Certification

    Fraudulent statements or intentional misrepresentation shall be considered sufficient cause for denial of service.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Page 13 of 15

  • Flight Request Acknowledgements

    Please read carefully and sign.
  • 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:

    • Service Dog Retrieval and/or Training: Miracle Flights will consider requests to fly the service dog patient (regardless of age) and UP TO one additional parent/legal guardian/family member (up to 2 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.

  • Clear
  • Page 14 of 15

  • 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: