Personal Assistive Device Donation Form COVID-19 Notice:Please read our current Announcement for Personal Assistive Device Request/Donations here before submitting this Personal Assistive Device Donation form. To donate a personal assistive device, please use this form. NOTE: Before clicking "Submit" please be sure you have filled out ALL fields marked with a red *If you do not see the "Thank You" page after clicking the Submit button, please check the form to make sure you have filled in ALL required fields.If you would rather fill out a printed form, please download/print this PDF form and send it to us. PLEASE NOTE: Your donation form must be accompanied by a current picture(s) of the piece(s) of equipment being donated, so we can determine whether we are able to accept it. If you wish to receive an income tax receipt for your donation, it must be accompanied by a written evaluation from a reputable dealer.Name* First Last Date* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Telephone*Mobile phoneEmail* Are you a Langley Pos-Abilities Society member?*YesNoHow did you hear about us?What category of Personal Assistive Device are you donating?* Crutches Bed Rail Bath Rail Toilet Seat Booster Manual Wheelchair Bath Chair/Bench Power Chair Mobility Scooter Electric Wheelchair Walker Toilet Grab Bars Other List "Other" Donation ItemsDetails*Please give us as many details as possible, eg. “Powerchair for tall heavy adult, needs new battery”, or “Scooter in nearly new condition for small adult; has carrier basket and sunshade”. We will be contacting you to arrange for pick up.MakeModelYearColourUpload photo(s) of itemMax. total file size = 2Mb Drop files here or Accepted file types: jpg, gif, png. Additional Equipment/Accessories:Estimated Value of DonationWe take your privacy very seriously. Your information is not shared with any other agency or organization without your written consent.CaptchaCommentsThis field is for validation purposes and should be left unchanged.