Hope Air Travel Assistance Request Application

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Change preferred language here:
You will require the following information to proceed with this application:
  • Scheduled specialist medical appointment
  • Personal information for patient and eligible escort
  • Travel dates
  • Gross household income
Make sure you have the above information ready before moving forward with your application. 

Preliminary Eligibility

A Hope Air travel assistance application cannot be made without a confirmed medical appointment. Please return when medical appointment has been scheduled.


Unfortunately, Hope Air can only provide travel assistance for medical appointments that are covered by provincial health plans.


A Hope Air travel assistance application cannot be made without consent to contact the patient's doctors to verify appointments and related information.


Hope Air’s travel assistance application requires you to have the patient’s total household income figure available.  Please return when you have this information available.


Canadian commercial airlines require that all passengers have government-issued photo ID to fly.

Contact Information



Patient Information
















Requestor Information







NHTG Information
Please answer the following questions to determine the patient’s eligibility for the Northern Health Travel Grant (NHTG).  NHTG-eligible patients who receive flights through Hope Air will be required to submit a completed NHTG application form back to Hope Air.  For more information, please see our Help page. 
Please note: NHTG eligibility has no bearing on the approval outcome of this travel request.








This patient is eligible for the NHTG.


If this travel request is approved by Hope Air, once travel is completed, this patient will be required to submit a completed NHTG application form back to Hope Air. The NHTG application form needs to be signed by the patient, the referring and specialist doctors, and the escort (if applicable).  The patient and escort should also keep their flight boarding passes. When the NHTG application form is completed, please submit the form and boarding pass by mail to Hope Air.

For more information, please see our Help page

Escort Information





Escort must be 16 years or older.




Travel Information





A copy of this letter must be provided to Hope Air before bridge or ferry travel can be arranged. The patient’s doctor must request this letter from Health PEI on the patient’s behalf and a copy can be obtained from the doctor’s office, if necessary.
Travel Details







Select all that apply


Hidden Fields







Appointment Information

Referring Doctor Details




Medical Appointment Details










Specialist Appointment Doctor Details









Additional Travel Services

Volunteer Pilot Program
Hope Air has a Volunteer Pilot Program, in which private pilots, approved by Hope Air, fly patients in small private planes, rather than on commercial flights. For more information, please see our Help page.


lb

lb
Ground Transportation
Hope Air may be able to provide an Uber voucher for ground transportation from the airport in the patient's appointment city to their medical facility or accommodation location.

Overnight Accommodation
Hope Air may be able to provide overnight accommodation for patients who need to stay overnight to attend their medical appointment.










Guests will be responsible for any hotel damage costs, in the unlikely event any damages should occur. Guest credit cards will not be charged otherwise.

Household Information

Hope Air assists patients in financial need who must travel long distances to reach specialized medical care.  To qualify for support, patients must provide the total gross household income, from all sources, for all family members in the household.  Gross household income is for the last full calendar year as reported by all household members to the Canadian Revenue Agency.​

Household Size


Household Income

Please submit the total gross annual household income from the previous calendar year. Gross household income should include ALL income sources for ALL household members BEFORE tax deductions. Please refer to all household members' tax documents, plus any additional income received.


Gross household income includes, but is not limited to, full-time employment, part-time employment, self-employment, federal or provincial income, such as CPP, Old Age Security, disability assistance, child tax benefits, child support, pension, investment, or any other income.  You can verify gross income by reviewing household members’ Notice of Assessment or tax returns from the CRA.


$


Income Attestation
Hope Air may request income verification at any time. Failure to provide verification of household income in an acceptable format may result in denial of travel assistance.

Release of Liability, Waiver of Claims, and Assumption of Risks

This is a legal document by signing this document, you will waive certain legal rights, including the right to sue or claim compensation. Please read it carefully.


I am freely requesting to access and participate in financially assisted travel (including but not limited to by airplane, ferry, bus, or car), accommodations, and meals (the “Services”) organized or coordinated by Hope Air, a not-for-profit organization, for the purpose of accessing medical care. I understand that Hope Air may contract third parties to carry out the Services, including but not limited to commercial and private air carriers, hotels, and restaurants (the “Contracted Third Parties”). I understand that accessing and participating in the Services exposes me to inherent risk, including but not limited to the risk of property damage or injury associated with travel. While Hope Air strives to reduce these risks, they can never be completely eliminated.  I understand that it is my choice to access and participate in the Services.  I also understand that I do so at my own risk. In exchange for accessing and participating in the Services, I agree to all the terms and conditions set out in this document (the "Waiver and Release").

  1. I am aware and understand that the Services involve foreseen and unforeseen risks, dangers, and hazards, including but not limited to the risk of property damage, injury, or death. I acknowledge that I am voluntarily participating in the services. I freely accept and fully assume any and all of the risks, dangers, and hazards involved and the possibility of property damage, injury, or death, whether caused by the negligence of the Contracted Third Parties or otherwise.
  2. I expressly waive and release Hope Air and its  respective officers, directors, agents, employees, volunteers, heirs, assigns and successors (collectively, the "Organization") from any and all claims, demands, liability (under federal law or the law of any province or country), fees, expenses, and cost of any kind whatsoever, which I may have or may in the future have on account of, or in any way related to, directly arising, or alleged to have arisen from the Services, due to any cause whatsoever, including without limitation the negligence of the Organization, breach of contract, or breach of any statutory or other duty of care owing under occupier’s liability legislation or otherwise. I agree not to make or bring any such claim against the Organization, and forever release and discharge the Organization from liability under such claims.
  3. I agree that I will be solely responsible for all claims, demands, damages, costs, expenses, actions, and causes of action, whether in law or in equity, resulting from any loss, personal injury, or property damage arising from my access to or participation in the Services
  4. If any term or provision of this Waiver and Release is held to be invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Agreement or invalidate or render unenforceable such term or provision in any other jurisdiction.
  5. This Waiver and Release will be binding on me and my heirs, executors, administrators and assigns, and the Organization and its successors and assigns.
  6. This Waiver and Release will be governed by and construed in accordance with the laws of the province of Ontario and the applicable federal laws of Canada.
  7. I acknowledge that I have had an opportunity to read this document and fully understand its terms and have had an opportunity to seek clarification concerning its terms. I understand that if I have any questions regarding this document, I should obtain legal advice prior to signing it.
  8. I certify that I am over the age of 18 or if I am under the age of 18 that my parent or guardian will agree to sign this Waiver and Release and provide necessary documentation on my behalf.



Save my progress and resume later | Resume a previously saved form

Contact Information