Durable Medical Equipment Donation Form

Durable Medical Equipment Donations

We gladly accept donations of gently used durable medical equipment (DME) to support individuals living with ALS and other mobility challenges. Items such as wheelchairs make a life-changing difference for families in need. Your donation helps us provide access to essential tools at no cost to those who need them most.
We can accept equipment that is in good, working condition. We will accept technology (speech generating devices, etc) and power wheelchairs that are less than 3 years old. All equipment is accepted based on organization need and space available. Accepted equipment donations must be cleaned and sanitized before pick up and or drop off.
Upon completing this form, our office will be in touch to discuss item for donation,including method of donation (pick up or drop off).
Full Name

First NameLast Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Address (if Item pick up or donation acknowledgement is needed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Item(s) to be Donated

Other
Comments (Expand on number of items, or if Other)
I will need a Thank You Donation acknowledgement
Should be Empty:

Durable Medical Equipment Donations