Hope Air Travel Assistance Request Application

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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

Does the patient have a medical appointment booked?

Yes

No

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

Is the medical appointment covered by a provincial health plan?

Yes

No

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

Does the patient grant permission to contact their doctors and/or specialist appointment medical facility?

Yes

No

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

All individuals 18 and older require government- issued photo ID to board a commercial flight. Do the patient and eligible escort have appropriate photo ID?

Yes

No

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

Hope Air Internal Code

This field is for Hope Air internal use only. If you are not a Hope Air associate, please leave this field blank.

Internal Submitter

Contact Information

Associate Information

Hope Air Associate Name

If you are a Hope Air staff or volunteer member completing this form, please enter your name.

Requestor Information

Who is this request for?

Who should we contact for follow ups to this travel assistance request?

PatientRequestor

Patient Information

Patient First Name

Patient Last Name

Patient Preferred Name (if applicable)

Patient Gender

Patient's Preferred Language

Patient Birthdate

Patient Age

Patient Email

Patient Phone

Patient Address Information

Address Line 1

Address Line 2

City

Province

Postal Code

Is the patient's primary residence in the district of Algoma, Cochrane, Kenora, Manitoulin, Nipissing, Parry Sound, Rainy River, Sudbury, Thunder Bay, or Timiskaming?

YesNo

Before learning about Hope Air's services, how would the patient have accessed the long distance medical appointment?

Postpone or cancel appointment	Travel by ground transportation 4-8 hours
Travel by ground transportation 8-12 hours	Travel by ground transportation 12+ hours
Borrow funds to pay for travel	Someone else would have paid for travel
Patient would self-pay for travel

Requestor Information

Requestor First Name

Requestor Last Name

Requestor Email

Requestor Phone

Requestor Relationship to Patient - I am the patient's

Does the requestor live in the same household as the patient?

Requestor Organization Name

Requestor Province

Does the patient have a medical requirement for an escort to accompany them during travel?

YesNo

Escort Information

Escort First Name

Escort Last Name

Escort Date of Birth

Escort Age

Escort Gender

Escort must be 16 years or older.

Escort Email

Escort Phone

Escort Relationship to Patient - I am the patient's

Does the escort live in the same household as the patient?

Escort Province

Appointment Information

Referring Doctor Details

First Name or Initial

Last Name

Phone

Extension

Medical Appointment Details

Appointment Date

Appointment Time

What type of appointment is this?

What illness, condition, or procedure is the appointment for?

If the illness, condition, or procedure cannot be found in the list, please select Other with the condition's related category.

Medical Condition ID

Medical Facility Name

Medical Facility Address

Medical Facility ID

Medical Facility Name Not Found in List

Appointment Medical Facility Phone

Extension

Please upload appointment confirmation letter

Specialist Appointment Doctor Details

Do you know the details of the specialist appointment doctor?

YesNo

First Name or Initial	Last Name
Phone	Extension

Medical Facility Department Name If the patient is not seeing a specific doctor or does not know the doctor's name, please enter the known department details.	Coordinator Name
Phone	Extension

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

Number of adults in household

Number of children in household

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.

Total gross household income from the previous calendar year

$

Select all applicable household income sources

Employment income (e.g. full-time, part-time, contract, seasonal, self-employment, etc.)	Federal income (e.g. EI, CPP, Old Age Security, Veteran Income Support, etc.)
Provincial income (e.g. disability support, income assistance, etc.)	Insurance income (e.g. private insurance, workplace insurance, etc.)
Other non-government income (e.g. pension, investment returns, spousal support, etc.)	Child income (e.g. child tax benefits (federal and provincial), child disability income, child special allowance, child support, foster care allowance, etc.)

Has there been a substantial change in household income this year from the previous calendar year? If so, you may provide additional information here

Income Attestation

I confirm that I have reviewed the gross income for each household member of the patient and have included all income from all sources received by the patient and all other household members.

I confirm that the total gross household income I have stated above is accurate and true for the patient's household.

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").

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.
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.
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
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.
This Waiver and Release will be binding on me and my heirs, executors, administrators and assigns, and the Organization and its successors and assigns.
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.
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.
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.

I acknowledge that I have read and understood all of the terms of this waiver and release and that I am voluntarily giving up substantial legal rights (on my behalf and on behalf of my heirs, assigns, successors, executors, administrators, and next-of-kin), including the right to sue the organization.

Legal Name

Today's Date

Power wheelchair (patient's own)	Manual wheelchair (patient's own)
Other mobility aid (patient's own)	Airport wheelchair
Service animal	Visual impairment
Hearing impairment	Seizures
Severe allergies	Oxygen
Physical assistance required