MALL Contact Form

EmailPlease enter your email address so we can contact you. If you don't have an email address, click Next.

example@example.com

Phone Number* This field is required.Enter a phone number where we can reach you. Cell phone is preferred if you have one.

Please enter a valid phone number.

Name* This field is required.Name of the person filling out this form

First Name

Last Name

Subject* This field is required.How can we help you?

Request a Mobility Aid

Donate a Mobility Aid

Volunteer

Partner with Us

General Questions/Other

Partner Information* This field is required.Please tell us about your organization and how we can work together

Volunteer Information* This field is required.We welcome volunteers! Please tell us a little about yourself and any skills and talents you can share.

Questions and Comments* This field is required.How can we help you?

Mobility Aid Request* This field is required.I need...

Cane, crutches, walker, or rollator

Knee scooter

Manual wheelchair or transport wheelchair

Power wheelchair

Mobility scooter (electric)

Child size wheelchair

Mobility aid for kids (stander, tricycle, etc.)

Patient hoist or lift

Transfer board

Shower chair or commode

Air cast/walking boot

Not sure/would like to consult with MALL

Other

Do you have access to a power source to store and charge your electric wheelchair/scooter indoors for at least 8 hours every night?* This field is required.Power mobility devices are not waterproof and cannot be stored outdoors or in cold temperatures when not in use.

Yes

How do you typically travel within your local area? (Check all that apply)* This field is required.

Personal/family vehicle with ramp, lift, or hitch platform for a large, heavy scooter or wheelchair

Public bus or paratransit

Non-emergency medical transportation service with ramp/lift

Personal/family vehicle and someone lifts my wheelchair or scooter into the trunk or back seat

I don't have regular transportation

Other

Does your home have stairs to enter the area(s) where you will use the power scooter/wheelchair or store it when not in use?* This field is required.MALL does not provide wheelchair ramps due to budget and space limitations. We can recommend affordable ramps, but note that it can be very costly and complicated to ramp more than two steps. If you rent, per the federal Fair Housing Act, your landlord MUST allow you to install or use a ramp, but you must pay for the ramp.

No steps/I already have a ramp

One step or two single steps separated by several feet along the path to enter

Two steps

Three or more steps in a row

Other

Which type of power mobility device do you need or prefer?Check all that apply. Please note that our waiting list for folding/portable electric scooters and wheelchairs that fit in a car trunk can be up to 6 months. We usually have non-folding power wheelchairs in stock and ready to go within 1-3 weeks.

Any/First available

Standard 3 or 4-wheel mobility scooter

Standard power wheelchair

Power wheelchair with positioning features such as seat elevator, recline, and/or foot elevation

Lightweight folding mobility scooter (waiting list)

Lightweight folding power wheelchair (waiting list)

Most of our donated power wheelchairs and scooters need new batteries that can cost up to $300. Can you assist with buying your own batteries?Your answer will NOT affect your eligibility, but may affect how quickly we can provide you with a device, as our funds are very limited.

I can take the device as-is and pay for battery installation myself

I can cover the full cost of batteries but need them installed before pick-up

I can contribute up to $100

I can't afford any amount

This item is for* This field is required.Please choose your relationship to the person who will be using the mobility aid

Family member or close friend

Client or patient

Organization or event

Other

How will this item help you or the person who will be using it?Any information you choose to share here will remain confidential. It will only be used to help match you with the right mobility aid.

Mobility Aid Donation* This field is required.I'm donating a...

Cane or rollator (We are currently NOT ACCEPTING underarm crutches or standard walkers due to space limitations)

Knee scooter

Manual wheelchair or transport wheelchair

Power wheelchair

Mobility scooter (electric)

Child size wheelchair

Mobility aid for kids (stander, tricycle, etc.)

Patient hoist or lift

Transfer board

Shower chair or commode

Other

Item Condition* This field is required.Please choose the option that best describes the condition of this item

New and Never Used

Excellent

Good

Fair

Needs Minor Repairs

Needs New Batteries

Can you drop off your donation at our storage location in Bloomington?* This field is required.We prefer if you can drop off items, but if you can't, we can arrange pickup.

Yes

No, it is too large/heavy

No, I don't have transportation

Additional Donation Information* This field is required.Please tell us more about the item -- brand, age, if repairs are needed, etc.

Library Pick-UpGreat news! If you live in Monroe County, you can pick up this mobility aid at the Monroe County Public Library. Visit the downtown branch at 303 E. Kirkwood Avenue, Bloomington, IN 47408 and go to the second-floor service desk. You will need a valid library card, but they are free to County residents who can verify their local address. If you are NOT a Monroe County resident, please text us at (317) 759-1278 to arrange pickup by appointment. There are NO due dates or overdue fees for mobility aids -- keep the item as long as you need it!

Yay! I'll pick up this item soon

I'm outside the county and will text to arrange pickup

Library DonationGreat news! You can donate this mobility aid at the Monroe County Public Library. Visit the downtown branch at 303 E. Kirkwood Avenue, Bloomington, IN 47408 and go to the second-floor service desk.

Yay! I'll donate this item soon

Newsletter

Yes, please send me updates on available mobility aids and MALL events

Newsletter

Yes, subscribe me to this newsletter.

Contact Us to Set Up a Meeting TimeSince you're receiving or donating a large item, we'll need to set up a time to meet you at our storage location. Please text us at (317) 759-1278 with your name and the type of item you requested or are donating. If you only have a landline, you may call, but we strongly prefer texts. You should receive an email with the phone number above, but please write it down just in case. After we receive your text, we will be in touch within 5 business days.

Click here and then click Submit below to send your request!