Samaritan Fly-Along Application

Name  *Address  *Primary Phone  *Secondary Phone Age  *

Fly-along scheduling is based on the weight and balance of the fly-along guest in association with the on-duty crew. Due to the confined space within the aircraft, a height limit of 6’ 2” and a weight limit of 200 lbs. is strongly enforced. No fly-along will be permitted to weigh greater than 210 lbs., fully clothed with footwear and necessary outerwear, for their fly-along shift. Please provide an accurate height and weight below. FLY-ALONG GUESTS WILL BE WEIGHED UPON ARRIVAL to ensure an accurate weight and balance of the aircraft. All fly-along guests must be physically capable of entering and exiting the aircraft without difficulty.

Individuals must be able to fit into the assigned seat, with four-point safety belts in place, without interfering with patient care operations.

Current Weight  *Height  *Medical qualification: (please check all that apply) 

If Other was selected above, please specify: Parkview employees only: Department and extension** 

**Parkview Health employees are eligible for the fly-along program. However, availability for employees is limited, to allow greater opportunities for our emergency response partners.

Department/Service/Affiliation:  *

Please provide an emergency contact:

Name  *Phone  *Have you received a current Hepatitis vaccination?  *Have you flown along with Samaritan before?  *If yes, please provide the month and year of your previous fly-along(s). Fly-along scheduling preference: Please select your preferred days/time: (check all that apply) 

Other specific date or schedule request: Additional notes or requests