"Supporting the Nationwide Community of  Charitable Aviators"
Volunteer Pilot Organization
Referral System Listing Information and/or Membership Form

Please use this form to provide us information for your free listing on our website and for ACA telephone referrals.  

If you also wish to be a member group of the Air Care Alliance use this form for your 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.

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 is used to prepare general summary statistics for all volunteer flying and will not be published for particular groups.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
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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 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

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General Information to be used for summary statistics - an individual group's information will not be 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. Please make checks payable to Air Care Alliance.

  Optional and also immensely appreciated: We are a larger group 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: $______________

Signed

 x		 Printed Date
Title

 Email Phone

Please send this form and any payments to:  (Or - fax the form and mail any payment)         

Jeff Kahn, Treasurer          you may be able to fold the form so the address shows in a window envelope                       
Air Care Alliance
600 W. Germantown Pike, Suite 400
Plymouth Meeting, PA 19462                                        Fax:  815-572-9192

Provide any additional comments below or on other side of page. 

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