Personal Assistive Device Donation Form "*" indicates required fields Name* First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Telephone*Email How did you hear about us?(optional)DetailsPlease 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.Make(optional) Model(optional) Year(optional) Colour(optional) Upload photo(s) of itemOptional - Max. total file size = 2Mb Drop files here or Select files Accepted file types: jpg, gif, png, Max. file size: 2 MB. Additional Equipment/Accessories:(optional)Estimated Value of Donation(optional) Do you need a tax receipt?* Yes No We take your privacy very seriously. Your information is not shared with any other agency or organization without your written consent.CommentsThis field is for validation purposes and should be left unchanged. Δ