Test Flight Request Form with DV

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What is your primary reason for travel?*

Medical appointment

Domestic violence relocation

To provide care for a sick family member

To Attend a Funeral

Other reason

Unfortunately, we are not able to provide transportation for funerals.

We can often assist with other types of transportation needs. Please contact our office to discuss your situation at (310) 390-2958 or email coordination@angelflightwest.org.

How did you hear about Angel Flight West?*

Is the donated flight you need on or after Sunday, June 8, 2025?*

Yes

Don’t Know

Generally, we require 5 business days advance notice to find a volunteer pilot for your flight. In some cases, we can accommodate shorter term requests.

You don’t need to know the exact date of your appointment in order to complete the flight request, however, we will need to have a firm appointment before we can start looking for volunteer pilots for your flight. Please be aware that we generally require 5 business days advance, but we can sometimes accommodate shorter term requests.

Do you have a healthcare provider from whom we can request a medical release for you?*

Yes

Don’t Know

A medical release is signed by your physician indicating that you are medically stable and able to fly in a small, unpressurized aircraft. This is critical to insure the passenger’s safety.

Before we can start looking for volunteer pilots to fly you, we will need to have a physician verify that the passenger is medically stable and able to fly in a small, unpressurized aircraft and that a passenger’s condition will not affect the safety of the flight.

Are you able to board a small aircraft and sit up in a seat with a seat belt fastened around you?*

Yes

Don’t Know

Help: Watch aircraft boarding video

The cabin of a small aircraft is about the size of a sports car. Most require a step up to board. You must be able to walk to aircraft and board without assistance. Per FAA regulations, you must be able to sit up with a seatbelt fastened around you for the duration of the flight.

Angel Flight West flights are generally flown by volunteer pilots in their own aircraft. Our pilots are not medically trained and their aircraft are not equipped to accommodate medical equipment. To comply with FAA regulations, any passenger must be able to sit up and fasten a seatbelt around them. For this reason, the passenger must meet these criteria in order to use Angel Flight West. If you are not ambulatory, we can sometimes accommodate you on a commercial flight.

Please consult the help text to get more specifics about what is involved with boarding a small aircraft.

Do you have a financial need or a compelling reason why you can't use public transportation?*

Yes

Don’t Know

Angel Flight West is a charitable service serving people in need. Our pilots donate the cost of the flights because they want to help people in need. Compelling need might also include persons who are immuno-compromised or can’t fly commercially for other reasons.

Angel Flight West flights are flown by volunteer pilots who donate their time as well as the costs of the flight. Angel Flight West is a charitable service serving people in need. For this reason, we require that passengers have a financial need, or have a compelling reason why they cannot travel commercially.

Please consult the help text to get more specifics about what we mean by financial need or other compelling reasons.

How did you hear about Angel Flight West?*

Passenger's First Name*

Passenger's Name*

Passenger's Phone*

Passenger's Email*

How soon does the passenger need to travel?*

How many companions will be traveling with the passenger?*

Is the passenger currently in a domestic violence shelter or a safe house?*

Yes

AFW doesn’t consider residences of friends or family members to be safe houses. Safe houses are secure locations operated or managed by a domestic violence provider in which survivors can have their basic needs met while they figure out the next step.

Name of the Shelter or Safe House where the passenger is currently residing

Does the passenger have an advocate or provider of domestic violence services who can intercede and manage the flight request on your behalf?*

Yes

Advocates or providers of domestic violence services can come from non-profit organizations, police departments, fire stations or hospitals.

Please provide the name of and contact information for the advocate or domestic violence services provider who can intercede and manage the flight request on your behalf.

Advocate First Name

Last Name

Advocate/Shelter Phone Number

Advocate or Shelter Contact Email

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Where will this flight begin and end?

I’m not sure yet where I will be treated

You don’t need to know the exact location of your appointment in order to complete the flight request, however, we will need to have a firm appointment before we can start looking for volunteer pilots for your flight. Please be aware that if the location falls outside our territory, we may need to refer you to another organization.

Passenger's Current Location: City*

Passenger's Current Location: State*

Destination City*

Destination State*

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Destination State*

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Destination City*

Test Flight Request Form with DV

Need a Flight Rev March 2022 with DV

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