Request a Flight

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Date of Request
MM slash DD slash YYYY
New Luke's Wings Hero?*
Is this request for a Service Member who is new to Luke's Wings, or a Service Member we have already worked with?
- New to Luke's Wings
- Recurring Applicant
How many passengers will need to travel?

Service Member’s Information
Please let us know about the Hero requesting assistance, and a little about their service.
Service Member Name*
First Last
Date of Birth*
Gender*
What is the service member's gender?
Race*
What is the service member's race?
Rank*

Please provide the Service Member's rank.
Branch of Service*
Please provide the Service Member's branch of service.
Date Entered Service
When did the Service Member enter service?
Location*

Where is the service member currently located?
Duty Location

Please let us know at least one location where the Service Member served.

Best Individual to Contact
This individual may be the Service Member, the veteran, or the passenger travelling. Luke’s Wings needs a reliable individual who will be responsive to future correspondence regarding the travel.
Relationship to the Service Member*
Contact Name*
First Last
Contact Phone Number*
Contact Email*
Contact Address of Record*
Street Address City State ZIP Code

Current Circumstances & Treatment Information
Please tell us about your medical circumstances and a little about your current treatment.
Name of Medical/Treatment Facility*

Please tell us where the applicant is located.
Estimated Length Of Treatment Remaining
Injury Description/Medical Diagnosis*
Please tell us a bit about the service member's injury/medical diagnosis.
If applicable, what were the circumstances in which the service member/veteran was injured or diagnosed?
Please provide your answer in the form of a story and provide as much detail as possible.
If applicable, what is the service member/veteran’s recovery program?
Tell us a bit about the program the service member is currently involved in.

More About the Service Member
Tell Us About the Service Member*
Please tell us about yourself and your family, your hobbies, your dreams. If this application is being filled out by a family member, please tell us about the Service Member and please tell us their story.
Financial Considerations
Are there financial considerations we should know about?

Verification Information
Luke’s Wings requires either a case manager, social worker, nurse/doctor, or other professional within the chain of care.
Professional's Name*
Prefix First Last Suffix
Professional's Relationship to Service Member*
Professional's Phone Number*
Professional's Email
Attach any relevant forms or documents
Max. file size: 128 MB.

First Passenger
For verification purposes, please provide the passenger's full name as shown on license or other appropriate legal documentation.
First Passenger's Name*
First Middle Initial Last
First Passenger's Relation To The Service Member*
First Passenger's Date Of Birth*
First Passenger's Gender*
First Passenger's Phone Number*
First Passenger's Email*
First Passenger's Flight Options*
- Roundtrip
- One-Way
First Passenger's Preferred Departure City Airport*
First Passenger Secondary Departure City
First Passenger's Preferred Arrival City Airport*
First Passenger's Secondary Arrival City
First Passenger's Departure Date*
MM slash DD slash YYYY

Please select your preferred departure date.
First Passenger's Return Date*
MM slash DD slash YYYY

Please select your preferred return date.

Second Passenger's Information
For verification purposes, please provide the passenger's full name as shown on license or other appropriate legal documentation.
Second Passenger's Name*
First Middle Initial Last
Second Passenger's Relation To The Service Member
Second Passenger's Date Of Birth
Second Passenger's Gender
Second Passenger's Phone (If known)
Second Passenger's Email (If known)
Second Passenger's Flight Options
- Roundtrip
- One-Way
Second Passenger's Preferred Departure City Airport
Second Passenger's Secondary Departure City
Second Passenger's Preferred Arrival City Airport
Second Passenger's Secondary Arrival City
Second Passenger's Departure Date
MM slash DD slash YYYY

Please select your preferred departure date.
Second Passenger's Return Date
MM slash DD slash YYYY

Please select your preferred return date.

Third Passenger's Information
For verification purposes, please provide the passenger's full name as shown on license or other appropriate legal documentation.
Third Passenger's Name
First Middle Initial Last
Third Passenger's Relation To The Service Member
Third Passenger's Date of Birth
Third Passenger's Gender
Third Passenger's Phone (If known)
Third Passenger's Email (If known)
Third Passenger's Flight Options
- Roundtrip
- One-way
Third Passenger's Preferred Departure City Airport
Third Passenger's Secondary Departure City
Third Passenger's Preferred Arrival City Airport
Third Passenger's Secondary Arrival City
Third Passenger's Departure Date
MM slash DD slash YYYY

Please select your preferred departure date.
Third Passenger's Return Date
MM slash DD slash YYYY

Please select your preferred departure date.

Fourth Passenger's Information
For verification purposes, please provide the passenger's full name as shown on license or other appropriate legal documentation.
Fourth Passenger's Name
First Middle Initial Last
Fourth Passenger's Relation To The Service Member
Fourth Passenger's Date of Birth
Fourth Passenger's Gender
Fourth Passenger's Phone (If known)
Fourth Passenger's Email (If known)
Fourth Passenger's Flight Options
Fourth Passenger's Preferred Departure City Airport
Fourth Passenger's Secondary Departure City
Fourth Passenger's Preferred Arrival City Airport
Fourth Passenger's Secondary Arrival City
Fourth Passenger's Departure Date
MM slash DD slash YYYY

Please select your preferred departure date.
Fourth Passenger's Return Date*
MM slash DD slash YYYY

Please select your preferred return date.

Fifth Passenger's Information
For verification purposes, please provide the passenger's full name as shown on license or other appropriate legal documentation.
Fifth Passenger's Name
First Middle Initial Last
Fifth Passenger's Relation To The Service Member
Fifth Passenger's Date of Birth
Fifth Passenger's Gender
Fifth Passenger's Phone (If known)
Fifth Passenger's Email (If known)
Fifth Passenger's Flight Options
- Roundtrip
- One-way
Fifth Passenger's Preferred Departure City Airport
Fifth Passenger's Secondary Departure City
Fifth Passenger's Preferred Arrival City Airport
Fifth Passenger's Secondary Arrival City
Fifth Passenger's Departure Date
MM slash DD slash YYYY

Please select your preferred departure date.
Fifth Passenger's Return Date
MM slash DD slash YYYY

Please select your preferred return date.

Group Visit
With six or more passengers, Luke's Wings staff will need to contact you collect the necessary details for all of your passengers.
How many passengers will be traveling?*
Please enter a number greater than or equal to 6.

Visit Details
Please tell us why you chose these people and this time?*
Please share with us a bit more about the nature of this trip.
When was the last time you saw them?
Are there any other considerations we should be aware of?
Special Requests
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Email
This field is for validation purposes and should be left unchanged.

Eligibility

Important Reminders

What to expect

Request Travel

Step 1 of 13 - New Request

Service Member’s Information

Best Individual to Contact

Current Circumstances & Treatment Information

More About the Service Member

Verification Information

First Passenger

Second Passenger's Information

Third Passenger's Information

Fourth Passenger's Information

Fifth Passenger's Information

Group Visit

Visit Details

Contact Us

Media Kit & Logo

Terms & Privacy Policy

Request a Flight

Eligibility

Important Reminders

What to expect

Request Travel

Step 1 of 13 - New Request

Service Member’s Information

Best Individual to Contact

Current Circumstances & Treatment Information

More About the Service Member

Verification Information

First Passenger

Second Passenger's Information

Third Passenger's Information

Fourth Passenger's Information

Fifth Passenger's Information

Group Visit

Visit Details

Stay Involved

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Contact Us

Media Kit & Logo

Terms & Privacy Policy

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