In-Kind Donation Request Form

In-Kind Donation Request Form
PATH TO MOBILITY PROJECT PRODUCT REQUEST

The submission of this application shall serve as proof that all information is complete and truthful. Further, the applicant certifies that all options to obtain coverage and payment from insurance(s) have been attempted and exhausted. Any incomplete applications will be rejected.
Client Name*

First NameLast Name
Client Email*
example@example.com
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Client Age *
Client Diagnosis (please describe/no medical codes). *
Insurance Information

IMPORTANT: All insurance options MUST be submitted and denied PRIOR to application submission and MUST be included with the application. Please attach a copy of any documentation with the primary insurance provider and denial.
MedicareMedicaidPrivate insurance (Please list)
Please provide the name of private insurance provider, if applicable.
2. What item(s) requested were denied by your primary insurance? Please list below, in order of medical need.*
YesNo
YesNo
If yes, please identify insurance provider.
5. If the answer to question 4 is yes, please describe what item(s) were denied by your secondary insurance provider. Please list in order of medical need.
STATEMENT OF NEED: We invite you to share a personal narrative explaining the unique impact this contribution will have on your life, aside from its medical benefits. Describe the WHY - the personal significance of this gift and its role in enhancing your quality of life. How will this gift contribute to your personal empowerment in your daily life? Examples: "I will be able to reach my locker at school or be able to participate in the choir at church."or "I will be able to accompany my daughter down the aisle on her wedding day." We want to understand the real-world impact of this donation on your life and why you feel uniquely qualified to receive this product donation.
Please write your answer here.*
CERTIFICATION AND ACCEPTANCE: I certify that information contained herein is true and complete and accept the obligation to comply with the terms and conditions if the request is awarded as a result of this application. Non-Discrimination: Path to Mobility Project, Inc. will not make contributions that discriminate on the basis of race, color, religion, gender, mental or physical disabilities, sexual orientation, national origin, age, citizenship, veteran/reserve/national guard status or other protected status; partisan political organization; or groups limited to members of a single religious organization.

PUBLICITY WAIVER AND RELEASE AGREEMENT: I hereby irrevocably permit, authorize and license to Path to Mobility Project, Inc. and its licensees, assigns, successors, parent company, subsidiaries, owners, operators, and other affiliates, and each of the respective officers, directors, employees, shareholders, contractors, agents, associates, and representatives, (collectively “Assignees”), the universal, unrestricted and perpetual right to use my name, image, likeness, voice and/or appearance as such may be embodied or recorded in any photos, video recordings, audiotapes, digital images, or any similar medium, (collectively “Information”). I understand this waiver and release signifies that the Information described herein may be electronically displayed via the Internet or via any other medium with no time limit on or geographic limitation to which these materials may be distributed. By signing the in-kind product application and/or sponsorship application, I hereby waive any right that I may have to inspect and/or approve the finished works or the use(s) of the Information. I further hereby release, discharge and agree to hold harmless Assignees from any liability, any claim or cause of action, whether now known or unknown, for defamation, invasion of privacy, publicity or personality or any similar matter, or based upon or relating to the use and exploitation of the Information.

PARENTS OR GUARDIANS OF CHILDREN UNDER AGE 18 MUST SIGN THIS RELEASE: I am the parent or guardian of the minor named above. I hereby make and enter into each and every representation, license and assignment described above on behalf of me, the minor, and any other parent or guardian of the minor. I believe and represent that I have legal authority to make these representations, grant this license and assign the Information to Assignees, and I agree to indemnify Assignees for all liability arising out of any lack of authority on my part to make such representations.
Signature*

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If you have any questions about completing this form, please email: info@path2mobilityproject.org.Thank you.
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In-Kind Donation Request Form

PATH TO MOBILITY PROJECT PRODUCT REQUEST

Insurance Information