ALS Equipment Donation Form
The ALS Association accepts donations of Durable Medical Equipment (DME), adaptive devices, communication devices, as well as assistive technology, from individuals or families affected by ALS. Please complete this form and a team member will follow up with you. We are only able to accept equipment that is less than five years old and in good working condition. We are unable to take medical supplies, such as respiratory, formula, medications, etc. The ALS Association will provide you with a letter of acknowledgment for your donations. Values will not be assigned.
Name of Person Living with ALS
*
First Name
Middle Name
Last Name
Suffix
Address where equipment will be picked up
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of person contacting the ALS Association
*
First Name
Last Name
Relationship to person with ALS
*
Please Select
Spouse
Child
Niece or Nephew
Sibling
Friend
Caregiver
Other
Please tell us how you know the person you are assisting.
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mobility Aids
Walkers (2 or 4 wheeled)
Canes
Manual Wheelchairs
Power Wheechairs, Group 3 and portable
Transport Wheelchairs
Scooters ( 3 or 4 wheeled)
Wheelchair Cushions
Ramps (threshold or portable)
Transfer Devices
Hoyer Lift (power or manual)
Sit-Stand Lifts
Pivot discs
Beasy boards or sliding boards
Transfer/gait belts
Bathroom Equipment
Power toilet assists
Shower Chairs
Tub transfer and sliding benches
Tub slide shower systems (ex. Nuprodx)
Toilet safety frames
Rolling shower/commode chairs
Bedroom Equipment
Mattresses (alternating pressure relief systems only)
Mattress overlays with pumps
Bedrails
Over the bed tables
Bed cradles/blanket supports
Miscellaneous
Adaptive Devices for use in ADLs (activities of daily living)
OBI feeding devices
Communication/Assistive Technology
Speech Generating Device with Eye Gaze (ex. Tobii)
Tablet (IPad, Surface Pro, etc.)
Mounts for communication devices or tablet
Submit
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