Flight Request Form

Flight Request Form

This form is encrypted for enhanced security.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requesting Agency:
(Point-of Contact (POC) Name):
Alternate Agency:
(Point-of Contact (POC) Name):
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Survivor Location

Provide Details about the survivors location
1. Is/Are the survivor(s) in a safe place?
a. City, State:
b. How long have they been in that location?
c. How long can they stay safely in that location?
d. Is there a specific date and time when they will be released?
Safehouse
2. Do they have a Christ-centered safehouse program selected?
If yes, please enter information below. If no, where would they like to go?
a. Program Name:
b. City, State:
3. When is their acceptance date into a program?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Survivor Info
4. What is the biological sex of each survivor?
5. What is the weight of each survivor?
6. When was the last time the survivor(s) used drugs or alcohol?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time
7. Has the survivor shown any adverse behaviors, such as anxiety, violent outbursts, or schizophrenia or other?
8. Are they currently on any medications If so, please list them below
9. What is the age of the survivor(s)?
10. Do they have children accompanying them?
11. Do they have devices in their possession that can be tracked, such as phones, computers, or tablets?
12. Are they currently being followed, tracked, or traced? Is there an ongoing threat or danger?
13. What forms of identification does the survivor have in their possession? Example; Driver's license, prescription, school i.d.?
14. What length of stay does the survivor prefer?
15. Which transportation option would the survivor prefer?
16. Are any of the survivor(s) pregnant?
17. How much luggage will the survivor(s) have? Approximate total weight in lbs.
How many of each:
Personal items,
Carry-on,
Checked bag.
Checked bags are discouraged due to size, weight, and financial constraints. In some cases, they will not be permitted.
18. Does the survivor speak English? If no, what languages do they speak?
19. Have arrangements for transportation been made from the sending agency to their airport? Please explain:
20. Have arrangements for transportation been made from the airport to their destination? Please explain:
Thank you for taking the time to complete this questionnaire.
Should be Empty:

Flight Request Form

Survivor Location

Safehouse

Survivor Info