To: Flight Coordinator

I understand that volunteer pilots of Wings for Children, Flight Division provide free air transportation service for qualified children needing or returning from medical treatment.

Patients Name: _______________________________ Date of Birth: __________________________

The individual listed above is a patient in my care who requires medical transportation:

From: ______________________________________ To: ____________________________________

For the following reasons: ______________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

who is ambulatory and physically able to be transported in a light, non-pressurized aircraft that is not equipped for any medical emergencies and has a legitimate medical need to avoid lengthy surface transportation.

Physician: __________________________________ Address: _________________________________

___________________________________ Telephone: ________________ Fax: ______________

Physicians Signature: ___________________________________ Date: _________________________

Please fax this letter to: Karole K. Jensen, Director

Wings for Children, Flight Division
Telephone: 843-448-9294
Fax: 843-448-6445