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Loan Closet Application Form
ALS Association New Mexico Chapter
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Email
*
Your email
Date of Completion
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MM
/
DD
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YYYY
Name
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Address, City, State, and Zip Code
Your answer
Phone
Your answer
Email
Your answer
Preferred method of contact
Phone
Email
Other:
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If other please explain below.
Your answer
Is this application for you or family member?
Yes for me
Yes for Family Member
I have no association with someone who has ALS.
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What type of assistance do you need?
Choose
Manual Wheelchair
Walker
Cane
Scooter
Class 2 Power Chair
Class 3 Power Chair
Ramp
Grab Bar
Cushions
Speech Amplifiers
Speech Assistance
Eye Gaze Technology
Medical Beds
Neck Braces
Bath Equipment
Transfer Chair
IPad Program
Do you have a prescription for requested items?
Yes
No
I`m not sure.
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The ALS Association New Mexico Chapter loan closet is for the use and benefit of individuals diagnosed with ALS. Once equipment is no longer needed for said patient please to return to the ALS Association New Mexico Chapter. By clicking below you are agreeing to these terms and agreements and will return all equipment borrowed to the ALS Association New Mexico Chapter.
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For further information or if you need assistance please call us at 505-323-6348 or emails us at
als@alsanm.org
.
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