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  • MedWish MedWorks Humanitarian Aid Application

  • 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 MedWorks.

    Fax to: 216-674-2320

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

    Once MedWish Medworks 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 MedWorks at info@medwish.org or 216-692-1685.

  • Section 1: Overseas Recipient

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  • 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.

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  • 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.

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  • 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?

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  • Section 4: Project Details

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  • Logistics

    Please note: This information is used to determine how best to meet your needs. Please answer honestly. We are sensitive to the fact that many of our partners do not have all the resources they need.

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  • Rows

  • 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.

     

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  • Medical Furniture

  • Medical Supplies

    Available medical supplies are categorized by use. For example, bandages are listed under "Wound Care" and oral airways are listed under "Respiratory & Anesthesia."

  • Medical Equipment



  • Section 5: Reporting Responsibility

    Feedback is a vital element of the Humanitarian Aid program at MedWish MedWorks. 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 will be due back to MedWish MedWorks 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 MedWorks 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 MedWorks 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 5: Reporting Responsibility

    Feedback is a vital element of the Humanitarian Aid program at MedWish MedWorks. 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 MedWorks 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 MedWorks 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 MedWorks 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.

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