WHEELCHAIR AGREEMENT FORM
PEOPLE WHO MAKE A DIFFERENCE FOUNDATION lends wheelchair to those who are temporally in need of one. You can borrow a wheelchair from us for up to 8 weeks. We ask for a DONATION OF $ 15.00 (FIFTEEN DOLLARS) AND A DEPOSIT OF $ 50.00 (FIFTY DOLLARS) which will be refundable when you return the wheelchair. This equipment is used and has been donated by its prior owner. Working in a common cause to give support to our community, we are here to ease the burden of the person and his/her family reaching more of those who need temporal help. Thank you for the opportunity of being in service of you. Marcia Romero Founder/CEO
Name (Lender To)
First Name
Last Name
Pick up date
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Month
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Day
Year
Date
Will return on
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Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
The amount of $65 (sixty-five dollars) must be paid upon delivery of the equipment by cash or via ZELLE (407) 739-0612.
Cliente Signature
Date Signed
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Month
-
Day
Year
Date
Submit
Should be Empty: