Mission Request – Airport – groundangels.org

WHEN are your travelling - DATE ?

Mission Date *

We MUST know when you are travelling

Mission Type

In Bound

Out Bound

IN Bound is TO the Med Center. OUT Bound is going OUT from Med Center

PATIENT INFO

Patient Name *

VET? *

Yes

Mark YES if Patient is a Military Vet

Patient Mobile# *

Please enter primary contact # for Patient

Preferred Comms method?

Call

Text

How can our Volunteer best contact you?

Patient Age *

PLEASE tell us the Patients Age

HGA WAIVER accepted *

Yes

Patient MUST agree YES to waive all liabilities. WAIVER can be viewed here https://groundangels.org/about-us/forms-downloads/liability-waiver/

Permission to use Mission IMAGES

Yes

Patient Email *

Traveling companion NAME

Companion Mobile#

Please provide your Buddy mobile in case we cannot reach you

Relationship

Tot# Pass *

TOTAL number of passengers in your group?

City *

Patient HOME City

State *

Patients HOME City / STATE /ZIP code is used to assist in grant/funding applications.

HOME Zip *

KEY MISSION DETAILS

PU Place(AIR only) *

Airport

Clinic

Hotel

Other

Where are we picking you up?

Use clock icon to set - time. When do you want to be picked up?

Airport & Flight Info

Airport *

We NEED to know - which AIRPORT ?

Airline Carrier *

We REALLY NEED to know the AIRLINE and flight#

Flight #

WE REALLY need your arriving HOUSTON flight #.

Terminal

BUSH Airport ONLY

Airport Notes

If ANGEL flight - what is the TAIL # , PILOT name and phone # ? Add any helpful notes here if needed.

Med Center Location

Med Center Clinic/Hotels (AIR only) *

Please drop down to pick your CLINIC or HOTEL location - otherwise fill your SPECIAL address below.

Special Address

Zip

Med Center Notes

Add any helpful notes here if needed.