COVID-19 Emergency Action Fund: In-Kind Donation Form

COVID-19 Emergency Action Fund: In-Kind Donation Form

Children’s National Hospital has received a tremendous amount of support from the community regarding donations of Personal Protective Equipment (PPE) and other critical supplies.

If you have been in touch previously regarding an in-kind donation or have a question about our needs, please complete the form below.

Name*

First NameLast Name

Company/Organization Name (if applicable)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number

Area CodePhone Number

Item(s) Being Donated -- Please include quantity.

Quantity*

Estimated Total Value of the Item(s)

If unknown, please write n/a.

Where were these items purchased/acquired?

What is the delivery/shipping method?

Have you already mailed these items?

YesNo

Please provide the tracking number:

Please provide the date that you plan to mail these items:

If you have been in touch with a Children's National employee about this donation, please include their name here:

If not, please write n/a.

Additional Information/Comments

Please sign electronically to confirm your contribution: