Personal Assistive Device Request Form COVID-19 Notice:Please read our current Announcement for Personal Assistive Device Request/Donations here before submitting this Personal Assistive Device Request form. To request 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. 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 looking for?* 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' Equipment you are looking forDetails*Please give us as many details as possible so we can match you up with an appropriate piece of equipment, eg. “Powerchair for tall heavy adult, or “Scooter for small adult." We will be contacting you to discuss your request.We 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.