Langley Pos-Abilities Society

"changing disabilities into possibilities"

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  • About
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    • Personal Assistive Device Request Form
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      • Pub Night 2013
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      • Pub Night April 2016
      • Canada Day 2016
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You are here: Home / Personal Assistive Devices / Personal Assistive Device Request Form

Personal Assistive Device Request Form

"*" indicates required fields

To receive equipment, you are required to be a member of the Langley Pos-Abilities Society. Membership entails a small annual fee of $15.*
Are you a Langley Pos-Abilities Society member?
To receive equipment, there is also a $50 PAD Fee for all equipment request applications. Have you already paid the PAD fee?*


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.
Please visit this page to become a member of Langley Pos-Abilities Society: Membership Application Form
Name*
MM slash DD slash YYYY
Address*
What category of Personal Assistive Device are you looking for?*
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.
Payment Method*
Sending an e-transfer via your online banking system is easy.
1. Log in to your financial institution's online or mobile banking and navigate to Interac e-Transfer Send Money.
2. Select the account you would like funds transferred from.
3. Add or select "Langley Pos-Abilities Society" and e-mail address "zosia@pos-abilities.org"
4. Type in the specified amount you are sending, along with a personalized message such as: "PAD Fee" in the message area.
5. Click "Submit" button.
Credit Card
This field is for validation purposes and should be left unchanged.

Welcome to Langley Pos-Abilities Society

Langley Pos-Abilities Society is a non-profit volunteer supported agency that helps improve the quality of life for people with disabilities, including those living with mobility issues, hearing loss, blindness, plus many other conditions requiring assistive devices. Read More

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