Mission Request – Airport – hga.vm-dev.site

Patient Email *

WHEN are your travelling - DATE ?

Mission Date *

We MUST know when you are travelling

Mission Type

In Bound

Out Bound

IN Bound is from Airport arrival TO the Med Center. OUT Bound is going to Airport.

KEY MISSION DETAILS

PU Place(AIR only) *

Where are we picking you up?

Airport

Clinic

Hotel

Other

Pick Up Time *

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

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?

How can our Volunteer best contact you?

Call

Text

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

TOTAL number of passengers in your group? *

Traveling companion NAME

LEAVE BLANK

Companion Mobile#

LEAVE BLANK

Please provide your Buddy mobile in case we cannot reach you

Relationship

Emergency contact NAME *

Required — who should we call if something happens to you during the ride?

Someone we can call in an emergency (not travelling with you).

Emergency contact PHONE *

City *

Patient HOME City

State *

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

HOME Zip *

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 Facility Location

Med Center Clinic/Hotels (AIR only) *

Special Address

Zip

Med Center Notes

Add any helpful notes here if needed.

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Note: If your request is not submitted/saved, please look up above for RED area and correct your entry.