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.