Form - html


"The Voice of Public Benefit Flying"

Volunteer Pilot Organization or Supporter
Referral System Listing Information and/or Membership Form

Please print and use this form to provide us information for your free listing on our website and for ACA web-automated, telephone, and email referrals.  Set the printing size so the width fits your printer page.

If you also wish to be a member group of the Air Care Alliance use this form for your individual or group's membership application, too.   Membership is not required for listing or referrals, but we do encourage groups to join and work with us to improve the work of all public benefit flying organizations and their volunteers.  A Member of the Air Care Alliance must be an independently administered valid nonprofit public benefit organization or have an application pending for such status, and must agree with and subscribe to the principles guiding the Alliance, as expressed on our website www.aircareall.org.  We also welcome supportive individuals, companies, and other organizations.

It is important that you provide the most up to date facts about your organization so we can make appropriate referrals for you, whether you wish to become a member group of ACA or not.

Note: any information about number of missions, distances, etc. is used to prepare general summary statistics for all volunteer flying and will not be published for particular groups.  Estimates may be used.  Outside inquiries about a specific group's activities will be referred to that group's listed contact.

This information will be updated on a periodic basis.  If your information changes please let us know.  Please also review the information we provide in your listing on our website and let us know if any changes are needed. Please provide as much information as is easily available - we can add more later if needed.

Organization name: Office
Phone
Address line 1 Toll free
phone
Address line 2 Fax
City, State, Zip Night/24 hours

 

 

 

 Email address for organization's public listing

 Website URL
Primary contact name

Title

   Email

Phone

Secondary contact name

Title

   Email

Phone

    check this box if information is the same as in our prior form and/or as now shown on ACA website and fill in missing items only

PRIMARY Type of Public Benefit Flying Activity - check ONE - and provide nonprofit status and type:
Ambulatory Patient Transport   Environmental/Conservation Nonprofit organization
Air Ambulance for nonambulatory patients   Emergency/Disaster Relief   Type of nonprofit:
Non patient medical transport / clinics
  Other: Describe 
OTHER Types of Public Benefit Flying Activity provided - check ALL that apply:
Ambulatory Patient Transport   Environmental/Conservation     
Air Ambulance for nonambulatory patients   Emergency/Disaster Relief     
Non patient medical transport / clinics   Other: Describe 
Check every region and/or every state served by just your group, whether for a departure or arrival location. If you work as part of a larger or national group, list only the states from which your group originates flights, not the entire U.S.
  Continental USA
           - all 48 states
Canada Mexico  Central America South America
  Other countries or international regions (please list). If this varies then simply list "International":
Alabama Hawaii Michigan North Carolina Utah
Alaska Idaho Minnesota North Dakota Vermont
Arizona Illinois Missouri Ohio Virginia
Arkansas Indiana Mississippi Oklahoma Washington
California Iowa Montana Oregon West Virginia
Colorado Kansas Nebraska Pennsylvania Wisconsin
Connecticut Kentucky Nevada Rhode Island Wyoming
Delaware Louisiana New Hampshire South Carolina  
D.C. Maine New Jersey South Dakota  
Florida Maryland New Mexico Tennessee  
Georgia Massachusetts New York Texas  

 

General Information to be used for summary statistics - an individual group's information will not be shared or publicized:
No. of Years group operated: No. of Missions Coordinated last year No. of paid staff
No. of Pilot Volunteers  Estimated Mission Flight hours last year Year used for your statistics
No. of Other Volunteers Estimated average miles per mission  

Certification: Please check all appropriate boxes, then sign and send this form via fax or mail to the address shown.

  Please list our group and provide referrals to us as a non-member Public Benefit Flying organization. 

  Optional but very preferred: Please also accept this application for voting membership as an Air Care Alliance Member Group. Our $100 annual dues is enclosed or being sent separately. I understand that a Voting Member of the Air Care Alliance must be an independent valid nonprofit public benefit organization or have an application pending for such status, and I certify that my group meets those criteria and subscribes to the principles of the Air Care Alliance.

  Optional and very much appreciated: I / We wish to support the work of the Air Care Alliance as an individual, a supporting company or group, or we are not a nonprofit group or we are a volunteer pilot group but not independently administered; please accept this application for a supporting non-voting membership as an Air Care Alliance Supporting Member. Our $100 annual dues is enclosed or being sent separately. Our additional contributions are described in the next paragraph. 

  Optional and also immensely appreciated: We are a larger groupor organization and/or have good resources and we wish to make an additional contribution to further support the annual conference,  communications activities, media relations, and other work of the Air Care Alliance.  Please accept the enclosed additional amount of  $100____   $250___  $500___   $1000___    Other Amount: $______________

TOTAL OF ABOVE - AMOUNT TO PAY BELOW:  $ ___________________

Signed

 x

Printed Date
Title

Email Phone

Please complete and sign this entire form and email a PDF scan of it (best method), or fax it, or mail it addressed as shown below.

Any payments may be sent by credit card or PayPal by using our online form below.

Or you may send a check, mailed to the address below.  Make checks payable to Air Care Alliance.

Forms may be emailed via PDF scan to mail@aircareall.org or faxed to 815-572-9192.

Mailing Address for mailed forms and/or checks:

Linda Tangen, ACA Administrative Director
1932 Gunnison Place NW
Albuquerque, New Mexico  87120

You may be able to fold the form so the address shows in a window envelope

Include your check for the total payable to Air Care Alliance   

or:    Pay via Credit Card / PayPal using button below and
indicate name on card or PayPal Account here:

NAME: ______________________________________________

 ---------------------------------------------------------------------------------------------
Thank you!  If you have additional questions please contact us at mail@aircareall.org