Mission Request Form

All forms must be completed-in-full by the patient with the exception of the Physician’s Release which must be completed by the patient’s physician and submitted before a flight can be considered.

  • Patient Info

  • Please enter a value greater than or equal to 0.
  • Please enter a value greater than or equal to 0.
  • Primary Care Doctor Info

  • Destination Treatment Facility

  • Additional Passengers

  • Passenger Name (not patient)Exact WeightBirthdateRelationship to patientPhone 
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  • Pre-Flight Information for Flight Recipients and Support Passengers:

    As with any mode of transportation, certain risks are present. You should also know that the same regulatory standards that apply to commercial charter or airline flights are not required to be followed by the volunteer pilot conducting your flight. Specific questions about how your flight will be conducted should be addressed to the volunteer pilot for the flight.

    Please remember that LifeLine Pilots are volunteers. They are not compensated or reimbursed for any of the costs involved in flying their own or rented aircraft. Please do not offer them payment of any kind since this would alter the flight status from charitable to commercial (as per FAA regulations). It is the generous and kind spirit of these individuals which makes it possible for us to offer our services at no charge so please don’t forget to say Thank You!

    Please read the following carefully and feel free to call us if you have questions.

    General Information about LifeLine Pilots’ flights:

    • You are responsible for being on time, and arranging your ground transportation, lodging/food while traveling;
    • Do not arrive with an unexpected support person. The Pilot may not have room or capacity for added weight. Also, Pilots often fill an empty seat with a Co-Pilot;
    • The aircraft are small, 4-6 seats (like a Volkswagon with wings.) You cannot lie down or walk around; there is no bathroom on board so visit airport facilities before departure.

    What must I take with me?

    • Bring adequate personal items, clothing change, and supplies in the event of a delay;
    • Bring cash and/or a credit card with you for unforeseen expenses in case your trip is delayed due to bad weather or other problems;
    • Only minimal luggage is allowed. One or two small to medium soft bags not exceed a 40 pound total. Additional luggage may have to be shipped at your expense. Luggage and personal effects may be subject to inspection.

    What if there are changes in my appointment or the flight?

    • If the date or time of your trip changes, you must immediately contact the LifeLine Pilots’ Mission Coordinator (800-8227972). This is extremely important!
    • All flights are weather dependent. You are responsible for having a back-up travel plan if it is critical for you to keep your appointment;
    • The Pilot will call you to confirm time/place of departure about 24 hours beforehand. Important Pilot, Aircraft and Airport Etiquette:
    • Your Pilot will designate your flight as a “compassion flight” with air traffic control;
    • No smoking is allowed in or near any aircraft.
    • Do not play with or move any aircraft parts of the aircraft, and do not step on the wing or try to enter the aircraft without specific instructions from the Pilot;
    • Leave the aircraft clean and report any damage or problem to the Pilot.
  • I have read the above and understand my responsibilities regarding my acceptance of this free flight. I realize that the Pilot retains the right to cancel due to changing weather or other circumstance. Also, it is my responsibility to have a realistic back-up plan and be prepared for unforeseen delays and have the financial resources to deal with this situation.