Wheelchair Request Form

If you know of a child under the age of 21, living in the USA, that is in need of a wheelchair and seeking a donation of one, please cut and paste this form then email to CapsOfLoveUSA@gmail.com with the following information for consideration: Note: Requests can also be made for repairs using this same form.

 

Child's location ( city and state)?  _____________ ___________________________________

Contact information ( child's name, parent's name)?___________________________________

Contact email address?__________________________________________________________

Child's age and condition(reason for needing a wheelchair)?____________________________

Replacing existing wheelchair or first time user?_____________________type?_____________

Can you pick up from West Palm Beach area?                YES____________NO____________

Requested wheelchair type: light Portable______heavy Manual _______ Motorized__________

Seat size needed(measured between side rails accross sitting portion)____________________

School attending?______________________________________________________________

Are you participating in Caps Of Love at this time? YES________________NO_____________   

If Yes, under what name/city/state?_______________________________________________

More information (your story):

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I will email you a measurement chart to have filled out by a therapist so we can select the correct wheelchair for your child. (No medical documents necessary. ___________________________________________________________________________