WNC Medically Fragile Kids Needs Request Form
This form is for the collaboration between Advocates for Medically Fragile Kids NC and The Parker Lee Project to get specialized medical supplies to medically fragile children in WNC. 
We can NOT distribute medication. If there is a medication need, please contact your County Manager. You  can Google your county name with "County Manager" after to find yours. They are a county elected official tasked with this job.
This information may be shared among other partners to ensure a rapid response. Submission of this form confirms you have granted permission for us to share.
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Date of request (if completing form for someone else, please put the date the need was shared) *
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Are you submitting this for your own family or someone else? *
Contact Info
Name of person completing this form *
Phone number of person completing this form *
Email address of person completing this form
Best method of contact for person completing this form *
First name of person needing supplies *
Last name of person needing supplies *
Phone number of person needing supplies *
Email address of person needng supplies
Best method of contact for person needing supplies *
Current Location (where should we send the supplies?)
Address *
City *
Zip Code *
County *
How long will you be at this location? *
Type of location *
Supplies Needed
Please fill out the section below with the supplies you need. Be very specific. If your child does not need supplies in a particular category, just leave it blank. Please be as specific as possible, and be sure to include quantities and sizes of requested items.
Enteral/feeding needs (feeding bags, g-tubes, Ferrell bags, etc.)
*Please specify product brand, size, and quantity needed*
Formula needs
*Please specify product, brand, and quantity needed*
Incontinence needs (diapers, chux, etc.)
*Please specify product, brand, size, and quantity needed*
Trach needs (trachs, HMEs, ventilator supplies, etc.)
*Please specify product, brand, size, and quantity needed*
Respiratory needs (nebulizer supplies, oxygen tubing, cannulas, pulse ox probes, etc.)
*Please specify product, brand, and quantity needed*
Suction needs (suction tubing, suction canisters, little suckers, etc.)
*Please specify product, brand, and quantity needed*
Syringe Needs- specify type of tip (catheter tip, luer lock, slip tip, enteral tip)
*Please specify product, brand, and quantity needed*
Wound care needs (tegaderm, tape, duoderm, etc.)
*Please specify product, brand, and quantity needed*
Other needs
Additional Information
Urgency of request *
Who else have you been in contact with about this need (so we can coordinate)? Please list below *
Anything else we need to know?
Disclaimer
We cannot guarantee that we will be able to fulfill your request; however we will do our best to do so and/or connect you with someone who can. This form should not be used for medical emergencies. If you have a medical emergency, please call 911.

By checking this box, I am communicating that I understand that Advocates for Medically Fragile Kids NC (AFMFK) cannot guarantee that my request will be fulfilled. I understand that these are volunteer-donated supplies and that AFMFK does not guarantee the supplies in any way, and I am releasing AFMFK from any liability in regards to the state and use of the supplies. I understand that AFMFK is not a medical provider, that AFMFK cannot make medical referrals or fulfill prescriptions, and that AFMFK is not providing medical advice in any way by fulfilling requests.
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