MISSION RECORDS

MISSION RECORDS

AIRPORT - Mission Request

WHEN are your travelling - DATE ?

Mission Date *
We MUST know when you are travelling
Mission Type


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

PATIENT INFO

Patient Name *
VET? *
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?
Patient Age *
PLEASE tell us the Patients Age
HGA WAIVER accepted *
Patient MUST agree YES to waive all liabilities. WAIVER can be viewed here https://groundangels.org/wp-content/uploads/2024/08/2024-Liability-Waiver.pdf
Permission to use Mission IMAGES
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) *
Where are we picking you up??
Pick Up Time *
Use clock icon to set - time. When do you want to be picked up?
Just checking - AM or PM ? *
PLEASE confirm PU Time - AM or PM ?

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
Important 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.