Equipment Loan Request Form
Thank you so much for your interest in the Equipment Loan Program through the ECRN+ in partnership with Assistive Technology of Ohio. If you have any questions while filling out this form please contact our Family Resource Coordinator, Amanda Kirby at amanda.kirby@ymcacolumbus.org. Please note that equipment deliveries/pick-ups will typically be on Wednesdays between 10am-4pm. *All equipment requests made now through 5/31/22 will be addressed in June in the order they were received. Thank you for your patience!*
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Primary Information
Date of request:
*
 -
Month
 -
Day
Year
Date
Primary contact person for request
*
First Name
Last Name
Relationship to person utilizing loan
*
Please Select
Parent
Caregiver
Therapist
Doctor
Self
Other
How did you hear about us?
*
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Individual Information
Child or Person Utilizing the equipment
Name of Individual
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Gender
*
Male
Female
Other
Approximate height/weight
If a minor, Name of child's parent/legal guardian
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why does the individual need this equipment?
*
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Professional Information
Complete only IF you are a professional requesting equipment on behalf of your agency, school, client, etc.)
Contact Name
First Name
Last Name
Title:
Name of Organization:
Address of Organization
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to individual utilizing equipment
On behalf of myself and the organization named above, I herby agree: (1) that I am a professional (Therapist, Clinician, Teacher, Etc.) actively working with the above named individual; (2) to make due inquiry and insure that the requested equipment meets the needs of the individual prior to use. (3) if the individual is a minor, I have the authority/permission to make this request on behalf of the child.
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Type of Equipment Requesting
Name/Description of the item
*
How much support is needed for the above item?
Name/Description of the item (if requesting more than 1)
How much support is needed for the above item? (if requesting more than 1)
If requesting multiple items, would you prefer:
Wait until all items are available simultaneously
Retrieve individual items as they're available
No preference
If the equipment requested is not readily available, may we place you on a wait list?*
Yes
No
*Please note: every effort will me made to fill your request as soon as possible. Due to the nature of our Equipment Loan Program and random intake of donations, we cannot guarantee the immediate availability of requested item(s).While you are on the wait list, we are pleased to offer toy interim services to help meet your equipment needs. We can assist in providing information on accessing alternative funding sources, grant and scholarship possibilities, insurance assistance, alternative loan programs, etc.
Who recommended the equipment (check all that apply)
*
Self
Physical Therapist
Occupational Therapist
Speech Therapist
Service Coordinator
Pediatrician
Behavior Specialist
Other
What is the purpose of this equipment (check all that apply)
*
Evaluation
Demonstration
Trial Use
Accommodation
Training
Other
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Equipment Support Person
*Please note: Due to the nature of some of the equipment loan as well as the recipient's safety, in majority of cases, a Support Person MUST be identified before we can process your request (i.e Therapist, Teacher, Doctor, Clinician)
Contact Name
*
First Name
Last Name
Title
*
Name of Organization
*
Address of Organization
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Relationship to individual utilizing equipment
*
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Equipment Retrieval
What is your preference for retrieval of equipment should it become available?
*
Deliver to my selected location (home, work, school, etc.) within 20 miles of 43219
I would like to arrange a mutual date/time to pick up the equipment at the Leonard Ave office.
Name of contact at delivery or contact who will be picking up:
*
First Name
Last Name
Address of delivery
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Important notes for delivery
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Signature of Person Completing Form
By completing this request, I understand that requests for equipment are filled based on availability of equipment; placing a request does not guarantee my request will/can be filled. Equipment utilized in this program is obtained by donation ONLY and original warranty, quality, accessories, components, etc. cannot be assured. I understand that due to the nature of the Equipment Loan Program it will take time to process my request and delivery estimates are available from the Equipment Loan Manager depending on the requested piece(s) availability. I agree that the information completed on this form is accurate and true to the best of my knowledge.
*
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