Lending Closet Application
Please fill out ALL fields if borrowing for the FIRST time.
A receipt will be sent to the email address you provide.
Phone Number (no spaces/dashes)
Maria - Secondary Storage facility
How did you hear about us?
Children's Hospital of Pittsburgh
Lemieux Children's Home
I understand that Reagan’s Journey is not warranting that the Equipment is fit for use of your child, and that I am solely responsible for the selection of the Equipment. I understand that items picked up will not be loaned or sold to anyone else.
I hereby acknowledge receipt of the following item(s) of medical equipment loaned to me by Reagan’s Journey for the applicant’s sole use and that this equipment will not be loaned or sold to anyone else. I acknowledge that this equipment will be used and that I will exercise ordinary and reasonable care.
I HEREBY RELEASE REAGAN’S JOURNEY FROM LIABILITY IN CONNECTION WITH THE USE OR POSSESSION OF THE EQUIPMENT. THIS RELEASE IS FOR ANY AND ALL LIABILITY FOR PERSONAL INJURIES AND PROPERTY LOSSES OR DAMAGE IN CONNECTION WITH THE USE OF THIS EQUIPMENT.
* By signing this document I also give permission to use photographs of child listed above to be published on behalf of Reagan’s Journey for educational purposes. Such photos may be used in flyers, brochures, presentations, our RJ website, social media, newspaper, and TV programs.
I agree to the terms
Type name to sign
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service