Medical Equipment Inquiry
From We Can't to We Can
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Resource Recycler
*
Friend/Family
Social Media
Website
Event
Other
Please list what piece(s) of medical equipment you are interested in?
*
What type of challenges are you facing receiving this equipment?
*
Insurance denial
Insurance waitlist
Financial hardship
Unable to find the equipment
Other
Please describe the challenges you face receiving this equipment? (Please be descriptive).
*
Was insurance or another method unable to help you before you came to us?
*
Yes
No
Other
Recipient of medical equipment (child, family member, etc)
*
First Name
Last Name
Recipient's age
*
-
Month
-
Day
Year
Date
Relationship to you
*
Child
Sibling
Family member
Other
What is the recipient's disability/ies?
*
Please list what medical equipment you are interested in:
*
Blue Mygo Stander Size 1
Bella's Bumbas Wheelchair
Green Otter Bathchair
Standz Stander Gray/Blue
Buddy Bike
Other
How would this equipment changed your life and/or the life of your recipient?
*
Are you willing to share your story and picture of recipient with our nonprofit?
*
Yes
Not at this time
Other
Would you be interested in being apart of our docuseries if you received the item you are inquiring about?
*
Youtube
Please pick a tentative date for us to record your interview:
-
Month
-
Day
Year
Date
Photo/Video Release & Permission: I hereby give From We Can’t to We Can, NPO permission to use my (or my child’s) story, photo(s), and/or video(s) for promotional, educational, or fundraising purposes in print, online, or any other media now known or later developed. I understand that these materials will be used to support the mission of the nonprofit and that I will not receive financial compensation.
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: