Global Outreach to Find Access Resources
Thank you for filling out this form to let us know about your access needs. We will be in touch as soon as possible to discuss what support we can provide.
Name of individual needing equipment *
Name of person filling out this form *
Where does the person live?
Country, State, and/or City
How old is this individual?
How can we contact you? *
Tell us more about this person's current situation, and what you hope we can help with. *
Mark any/all equipment this person currently has and/or uses: *
Mark any/all equipment this person does NOT have but may benefit from: *
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