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MALL Contact Form
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1
Email
Please enter your email address so we can contact you. If you don't have an email address, click Next.
example@example.com
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2
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.
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3
Name
*
This field is required.
Name of the person filling out this form
First Name
Last Name
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4
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
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5
Partner Information
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This field is required.
Please tell us about your organization and how we can work together
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Volunteer Information
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We welcome volunteers! Please tell us a little about yourself and any skills and talents you can share.
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Questions and Comments
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How can we help you?
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8
Mobility Aid Request
*
This field is required.
I need...
Cane, crutch, 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
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9
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
No
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10
How do you typically travel within your local area? (Check all that apply)
*
This field is required.
Personal/family vehicle with ramp, lift, or other accommodation for a large, heavy scooter or wheelchair
Personal/family vehicle and someone lifts my wheelchair or scooter into the trunk or back seat
Public bus
Paratransit or medical transit with ramp/lift
Taxi or rideshare service without ramp/lift
I do not have regular transportation
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11
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 cover the full cost
I can contribute up to $100
I can't afford any amount
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12
This item is for
*
This field is required.
Please choose your relationship to the person who will be using the mobility aid
Me
Family member or close friend
Client or patient
Organization or event
Other
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13
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.
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14
Mobility Aid Donation
*
This field is required.
I'm donating a...
Cane, crutch, 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
Other
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15
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
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16
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
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17
Additional Donation Information
*
This field is required.
Please tell us more about the item -- brand, age, if repairs are needed, etc.
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18
Library Pick-Up
Great news! 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. 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
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19
Library Donation
Great 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
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