Equipment Donation Form
By submitting this form, I confirm that the medical equipment listed is intended to be donated to From We Can’t to We Can and that I am submitting this form in good faith.I understand that the organization may begin planning, coordinating pickup, storage, or redistribution based on the information provided. I agree not to donate, sell, or transfer the listed equipment to another individual or organization once this form has been submitted, unless I notify From We Can’t to We Can in advance and receive confirmation that the donation is no longer needed.
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I agree to the donation commitment.
Name
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First Name
Last Name
Email
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example@example.com
Would you like a tax receipt for your donation? If you select yes, it will be sent to the email address above.
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Yes
No
I understand that From We Can’t to We Can does not assign a monetary value to donated items. If applicable, a donation acknowledgment letter may be provided for tax purposes, and it is my responsibility to determine the value of the donated equipment.
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I understand and agree.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
What items are you donating? How many of each? Please be as detailed as possible.
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Are you dropping off or requesting pick up?
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Dropping Off
Requesting Pick Up
We would appreciate it if you would take the time to categorize the item(s) you are donating. This helps us assess the needs of the community. Please select all that apply.
Toileting Aid (Devices that help with bathroom functions, such as a bathroom chair.)
Communication Aid (Devices that help with talking to other people, such as an Accent.)
Mobility Aid (Devices that help with daily movement, such as a wheelchair.)
Sleeping Aid (Devices that help with bedtime routines and throughout the night, such as bed with guard rails or a CPAP machine.)
Travel Safety Aid (Devices that keep the child safe while traveling, such as a car seat or harness.)
Feeding Aid (Devices that help the child during meal times, such as weighted utensils.)
Transfer Aid (Devices that help transfer children safely and securely, such as a Hoyer lift.)
Recreational Activity Aid (Devices that help children participate in hobbies, such as an adaptive video game controller.)
Sensory Aid (Devices that are intended to help with sensory processing, such as a fidget cube.)
Any questions, comments or concerns?
Upload a picture of all of the items you are donating (upload as many as possible.) This is used to assess the quality and condition of the equipment to be donated.
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DONATION AGREEMENTS & ACKNOWLEDGMENTS
By submitting this form, I confirm that I am the lawful owner of the medical equipment listed below, or otherwise have the legal authority to donate it to From We Can’t to We Can. I understand that once the equipment is donated and accepted, ownership transfers fully to From We Can’t to We Can, and the equipment becomes the property of the organization
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I confirm I have the right to donate this equipment.
I acknowledge that the donated equipment is provided “as-is”, and that From We Can’t to We Can makes no guarantees regarding future use, redistribution, or assignment to a specific individual or family. I understand that the organization reserves the right to: Inspect donated equipment, refuse items that do not meet safety, hygiene, or program standards, repurpose, store, or redistribute equipment at its discretion.
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I understand and agree.
I acknowledge that the donated equipment is provided “as-is”, and that From We Can’t to We Can makes no guarantees regarding future use, redistribution, or assignment to a specific individual or family. I understand that the organization reserves the right to: Inspect donated equipment, refuse items that do not meet safety, hygiene, or program standards, repurpose, store, or redistribute equipment at its discretion.
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I understand and agree.
No Financial Compensation: I understand that this is a charitable donation and that I will not receive financial compensation for the donated equipment.
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I understand and agree.
I understand that submission of this form does not guarantee immediate pickup or acceptance, and that a representative from From We Can’t to We Can may contact me to coordinate next steps.
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I understand.
By typing my name below, I confirm that I have read, understood, and agree to all terms listed above. I understand that this electronic signature is legally binding.
Submit
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