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Mobility Aid Need Form
While we cannot guarantee that MALL can fill your need immediately, knowing that you have this need will help us match you with the appropriate item when we receive it.
If you have a donation, please fill out the form here:
https://tinyurl.com/MALLbloomingtondonations
.
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* Indicates required question
Email
*
Your email
I need...
*
cane
crutches
walker
ankle-foot orthoses (AFOs)
rollator
lift
scooter
wheelchair
power electric wheelchair
other
not sure/would like to consult with MALL
Required
Anything you would care to tell us about your need?
Your answer
First Name:
*
Your answer
Last Name:
*
Your answer
E-mail Address:
*
Your answer
Phone:
*
Your answer
Can you pick up this item?
Yes
No
Clear selection
A copy of your responses will be emailed to the address you provided.
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