Please be sure to review the application instructions before proceeding.

Instructions:  Please complete this form and submit it. This application is also available as a PDF at the bottom of our International Aid webpage, which can be emailed, faxed or mailed back to MedWish.

Fax to: (216) 274-6380

Mail to: MedWish International, 1625 E. 31st Street, Cleveland, OH, 44114.

Once MedWish receives the application, we will follow up with you to discuss next steps or to request additional information.

Technical Assistance: If you have questions or technical issues with the application, please contact MedWish at info@medwish.org or 216-692-1685.

Section 1: Overseas Recipient

Section 2: United States-based 501(c)(3) sponsor

Please note that the US based sponsor is required to fulfill the following: 

1.   Verify the legitimacy of the operations of the in-country recipient and the appropriate usage of the supplies.

2.   Serve as a point of contact for logistical and operational purposes.

3.   Be listed as the Shipper of Record on shipping documents.

4.   Take financial responsibility for any costs incurred during the shipping process.

Section 3: Project Narrative

Organizational Information

Please describe the mission, history and programs of the recipient organization. Include information about the organization’s structure, staff and patient/client numbers.

Description of Need

Please describe the community or population the recipient organization serves, including leading health issues or diseases that are treated, data on poverty, conflict or disaster, and other information relevant to your program or project.

Description of Project Goals

What are the short and long-term goals of the recipient organization? How will the requested supplies and equipment support these goals?

Section 4: Project Details

Wish List

The wish list is a starting point for our staff to work with you to finalize a packing list. Please upload or use the text box below to provide us with a list of items you desire to have (dream big!). Please include quantities, sizes, and any specifications needed. We’ll work with you to prioritize and identify alternatives if needed.

 

Medical Equipment

Section 5: Reporting Responsibility

Feedback is a vital element of the Humanitarian Aid program at MedWish. It allows us to continually improve our services and programs to better support health care in developing countries. It also helps us secure continued financial support, donated supplies and volunteers.

A feedback survey (click here for sample) will be due back to MedWish within 60 days of your successful receipt of your shipment. Please complete the following form so that we can notify the responsible person to remind them.

By submitting this application, you consent to permitting MedWish to track and share information about the recipient organization and the sponsor organization for quality improvement, communications and fundraising purposes. Information included in the application as well as in the 60-day feedback report may be used for these purposes. You also agree that you will provide the feedback as requested below once a shipment is successfully completed.

If for any reason your organization cannot consent to publicizing details about your project please explain below. MedWish does not wish to put any recipients at risk and will respect confidentiality requests; however, we will require feedback from all recipients for internal record-keeping and quality improvement.

Please note: Failure to send complete and timely feedback report may disqualify the recipient organization from future shipments.

Section 6: Signature and Liability Release

Legal Statement

The medical supplies, equipment and materials available from MedWish International are items that would otherwise be discarded by healthcare facilities, individuals, and/or manufacturers in the United States. These materials are being made available strictly on an "as is" basis for the use by humanitarian relief organizations providing medical care in the developing world. MedWish International and the supply donors do not represent, warrant or imply that such materials are fit, appropriate, and free of defects, sterile, pure or suitable for any purpose. Supplies from MedWish may not be exchanged for money, property, or services.

Each recipient organization and recipient facility assumes full responsibility for making an independent determination of the appropriateness of each item of donation before using it. By submitting an application for the receipt of donated supplies, each organization and recipient facility releases MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials. 

Additionally, by checking the box below, you confirm that you/your organization will not provide donated goods to any of the restricted entities, persons, or organizations published by any member state of the European Union, the United States of America government, the United Nations, or other Governmental Authority, including the U.S. Treasury Department’s List of Specially Designated Nationals and Blocked Persons, Sectoral Sanctions Identifications List, and Foreign Sanctions Evaders List, the U.S. Commerce Department’s Entity List, Denied Persons List, and Unverified List, the U.S. State Department’s nonproliferation lists, and the EU’s Consolidated List of Designated Persons, (collectively, the "Sanctions Lists"), or are owned or controlled by a person or entity which is included on such Sanctions Lists. 

I have read and understand the above statement releasing MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials.

 

Submission of this form is an agreement of the above terms, however, you may be asked to fax/mail a signed copy of this agreement in the future.