Please This Complete Form
Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
I Would Like To:
*
Donate Equipment
Request Equipment
Donate Equipment
Describe the piece of equipment, device, or item you would like to donate.
Is the item in working order?
Yes
No
Are all the parts/pieces/chargers included with the donation?
Yes
No
Is the item foldable/collapsible?
Yes
No
Request Equipment
Describe the opiece of equipment, device, or item you need.
The next two questions help us understand the size of equipment that might be needed. We carry pediatric to adult sizes.
List the age of the person who needs the item.
What is the approximate the height of the person who needs the item.
Do you have a way to transport the item back to your home?
Yes
No
Submit
Should be Empty: