Local & Domestic Giving Program 1st Time Applicant

Local & Domestic Giving

First Time - Applicant Registration Form
MedWish's Local and Domestic Giving Program aims to connect vulnerable populations in need of medical supplies with the vast inventory MedWish maintains in its warehouse, through vetted agencies that help individuals with medical necessities, working together to promote their improved health and increased quality of life.

HOW WILL THE PROGRAM WORK?



Through its Local and Domestic Giving Program, MedWish will partner with local health and human service organizations/agencies to match its inventory with the needs of the community. Through this application process, MedWish will accept requests for supplies. MedWish will then review the request, match its inventory to the identified need, and organize a pick-up.

The program is open to all eligible social agencies and non-profit organizations. At this time, the original fee for service for this program has been covered by our generous donors. This is subject to change at any time and will be communicated to you in the event that a fee is reinstated. Shipping costs will not be covered and will be the responsibility of the recipient.

ELIGIBILITY:

For an organization/agency to be considered to receive donations (as part of MedWish’s Local and Domestic Program), they must:

-        Be a U.S. not for profit organization.

-        Setup an appointment with a MedWish representative.

-        Must not use donated surplus for sale or as a means for profit. The recipient organization must distribute the donated supplies directly to the recipient(s)/individual(s). The fee for service charged by MedWish is not allowed to be passed on to the recipient(s)/individuals.

-        Must provide timely and detailed feedback once donations are received.

-        Must demonstrate a commitment to serving all people regardless of age, race, gender, sexual orientation or religious beliefs.

-        Complete this application form.

**Please note that MedWish does not distribute medication. Prescriptions for supplies are not needed for distribution. Please DO NOT send prescriptions to our staff.**

For more information, please contact MedWish International at domesticaid@medwish.org or call 216.692.1685 x22.
PARTNER AGENCY FORM

Please be sure to review the application instructions before proceeding.

Once MedWish receives the application, we will follow up with you to discuss next steps or to request additional information.
Official name of organization/program: *
Sponsor Organization Type:*

SchoolSocial AgencyFaith-base group
Primary Administrative Contact*

First NameLast Name
Title*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Website
Phone Number*

Area CodePhone Number
Facebook Address
Primary on-site contact (if different from above)

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
PROJECT NARRATIVE*
How did you hear about this program?*

I've volunteered at MedWish beforeInternet searchI was referred by someone
If you were referred to MedWish by a person or organization, please let us know who:
ORGANIZATIONAL INFORMATION

Please describe the mission, history and programs of the organization/agency. Include information about the organization’s structure, staff and consumer numbers.
Mission, history and programs:*
EIN/Tax ID Number:*
501c3 Letter of Determination

Browse Files

Cancelof
Approximate number of staff:*
Approximate number of consumers served annually:*
Approximate number of consumers that will benefit from this request:*
Please indicate the race(s) of those your organization serves and the percent makeup of the population. *
Please indicate the predominant reason medical support is needed by those your organization serves.*
What is the economic status of those you serve?*
DESCRIPTION OF NEED

Please describe the community or population the organization/agency serves, including leading health issues and other information relevant to your program or project.
Need description*
How will the requested supplies and equipment support these needs?*
LOGISTICS AND PROCESSING/HANDLING FEE - Does the organization have the ability to pick up the donations?*

YESNO
Anticipated Payment Method *
IMPORTANT:

- Items will only be provided to partner agency representatives.
- Items will not be directly handed to any recipients; therefore, recipients should not try to pick up items from MedWish, or coordinate direct drop offs.
- If delivery is requested by the partner agency, please know that each drop off is subject to a $35 drop off fee (25 miles ratio).
- MedWish team will be responsible for unloading the item(s) from the truck. Partner agency representatives will be responsible for all transfer and movement of the item(s) once unloaded.

**Please note that MedWish does not distribute medication. Prescriptions for medical supplies are not needed for distribution. Please DO NOT send prescriptions to our staff.**
Who will be responsible for paying the processing/handling fee?*

Organization/agency contact listed on this formSponsor organization – If so, please notify the MedWish Rep.
WISH LIST

Please check any items your organization desires to have and we’ll work with you to prioritize, set quantities and sizes, and identify alternatives for requested items that are not available.

Remember: This list is an example of items commonly available in our inventory, but not a guarantee that any one item is available at this time. We will do our best to meet your needs to the best of our ability, and will work with you to substitute items or adjust your order when necessary.
Select needed equipment:

Crutches - $10eaIV Pole - $10eaNebulizer machine - $20eaOver-the-bed tray tables - $20eaShower chairs - $10eaWalkers (collapsible) - $10eaRollators - $25eaManual wheelchairs - $40eaBariatric Bed - $225eaHome health bed - $150eaWheeled lab stool - $10eaHoyer Lift - $40eaDisposable supplies - $2/lb.Specialized item
Please include any information about sizes, quantities or details for items if you know them. If there are any additional items you wish to request that were not on the list, or if you have any comments about the items you have requested, please briefly describe here:
REPORTING RESPONSIBILITY

Feedback is a vital element of the Humanitarian Aid program at MedWish. It allows us to continually improve our services and programs to better support health care. It also helps us secure continued financial support, donated supplies and volunteers. A feedback survey will be due back to MedWish within 30 days of your successful receipt of goods.

By submitting this application, you consent to permitting MedWish to track and share information about the organization/agency for quality improvement, communications and fundraising purposes. Information included in the application as well as in the 30-day feedback report may be used for these purposes.

If for any reason your organization/agency cannot consent to publicizing details about your project please inform the MedWish representative. MedWish 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. Failure to send complete and timely feedback report may disqualify the recipient organization/agency from future eligibility.
Name of person responsible for completing feedback report: *

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
CONSENT AND LIABILITY RELEASE

Legal Statement

The medical supplies, equipment and materials available from MedWish International are items received from healthcare facilities, providers, manufacturers and/or distributors in the United States – many of which would otherwise have been discarded. These materials are being made available strictly on an "as is" basis for the use by humanitarian relief organizations and social agencies. MedWish International and the donor facilities do not represent, warrant or imply that such materials are fit, appropriate, free of defects, sterile, pure or suitable for any purpose.

Each recipient organization/agency and recipient facility assumes full responsibility for making an independent determination of the appropriateness of each item of donation before using it. By submitting an application for the receipt of donated supplies, each organization/agency and recipient facility releases MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials.

I have read and understand the above statement releasing MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials. Submission of this form is an agreement of the above terms, however, you may be asked to fax/mail a signed copy of this agreement in the future.

Additionally, by checking the box below, you are confirming that you will not be working with any person or entities that are under trade or financial sanctions under the laws and regulations of the United Nations, the United States or any other jurisdiction that is applicable to the Rights and Services to be provided.
Applicant's full name*

First NameLast Name
Organization/Agency name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty: