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Available Equipment

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IF THERE IS AN ITEM HERE YOU WOULD LIKE TO CHECK AVAILABILITY ON,
PLEASE USE THE “REQUEST” BUTTON TO SUBMIT YOUR APPLICATION FOR CONSIDERATION.

THIS IS NOT A WISHLIST APPLICATION!!! Only applications for items listed here will be accepted.

This is a free Quality-of-life support program!  Although we never charge a donating or recipient family for these items,
donations are always appreciated in order to allow this program to continue.

If an item is marked Local Pick up Only – we are located in Melbourne Beach, Florida

 *** This list is in the continual process of being updated, so please check back often!

*** We are all volunteers so thanks for your patience :)

 

Medical Supplies

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GENTLY USED DISABILITY EQUIPMENT REQUEST FORM

Applicant Information
*First Name
*Last Name
*Address 1
Address 2
*City   *State   *Zip Code
*Home Phone   Alternate Phone
Fax Number   *E-mail Address

Child Information
*First Name
*Last Name
*Gender   
*Age   *Date of Birth Pick a date
*Height   *Weight
*Applicant's Relationship to this Child
*Diagnosis/Disability
*Primary Physician Name   *Phone
*Is this Child covered by Insurance or Medicaid?
If yes, name of coverage   Policy #

Other Funding
*Have all other sources for funding from insurance, Medicaid, Local, State and/or Federal programs been applied for?
    
*Equipment Requested
*Brief Statement
Please indicate how items(s) will improve quality of life for your child.
*What is 3+4?