AccessAbility First Foundation - Medical Closet Request Form 
Please fill out this form as detailed as possible. An incomplete request will not be answered or fulfilled.
A representative will attempt to contact you via phone, text, or email for further information regarding your request before approval-- after 2 attempts, the request will be cancelled. If a recipient fails to meet for a scheduled pick up time, all items will be returned to the closet program and will not be held. Otherwise, all items are always first-come, first-served. AccessAbility First Foundation will also do our best to fill wait list requests in order received as donations come in. You may request items once per quarter and we do not currently ship items outside of the Concho Valley area.


For further questions/concerns, please email jordandiibon@accessabilityfirst.org.
Sign in to Google to save your progress. Learn more
Email *
I authorize AccessAbility First Foundation to use photos of me for marketing, advertisement, and grant writing purposes. *
What is your address? Invalid or incomplete addresses will not be accepted.  *
Number of Household Members  *
TERMS AND AGREEMENT - 

1. I am aware that The Closet Program is supplied through donations and that my request may not be fulfilled within a specific time frame. All requests are fulfilled at the discrepancy of AccessAbility First Foundation staff.
2. I am aware that equipment and/or supplies I receive from The Closet Program are gently used. I am aware that AccessAbility First Foundation is not responsible for any broken equipment or missing pieces. I am aware that AccessAbility First Foundation is not responsible for any potential injuries that could be caused by equipment and or supplies. I release all liability from AccessAbility First Foundation. 
3. I am aware that selling and profiting from donated medical equipment and supplies is considered fraud. If there is any reason to believe such activity I will be disqualified from assistance from AccessAbility First Foundation. 
*
Reason for assistance  *
Phone Number *
Are you within 30 miles of San Angelo, Texas?  *
Is this item for a child or adult?  *
Choose size and number per color
What item are you requesting? BE VERY SPECIFIC, this will help us insure your needs are met promptly. Limit each form to 3 items, if you need more than 3 items please fill out another form. Please include sizes and/or measurements. *
Annual Household Income (this doesn't disqualify you, as it is for data purposes only) *
First & Last Name  *
How did you hear about us?  *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of AccessAbility First Foundation. Report Abuse