The sweethearts Foundation Wheelchair Request Form
Please fill in this form if you or someone you know of requires a wheelchair. We call this person needing help a beneficiary.

We promise to do our very best and will try to help in as short a time as possible but this is dependent on the availability of "Tops and Tags" collections and funding.

Please ensure that all information is submitted in full and double check your request before you click submit.

Email address *
Name and Surname *
Contact Number *
Terms and Conditions
Once this form has been completed, the beneficiary’s application will be processed and verified. All application forms will be kept private, but by applying for a wheelchair, you grant The sweethearts Foundation authority to verify if the beneficiary belongs to a medical aid. Once the application has been verified and the beneficiary is added to the Official sweethearts Foundation Wheelchair Waiting List, the beneficiary may or may not be required to be assessed by the Official Wheelchair Manufacturers of The sweethearts Foundation. Failure to complete the assessment as required by The sweethearts Foundation will result in this wheelchair request being declined. The sweethearts Foundation reserves the right to refuse a wheelchair request where necessary.

The sweethearts Foundation reserves the right to host a Wheelchair Handover Ceremony at a place, time and date which the Foundation deems fit. Once the Wheelchair Request has been submitted, the requester and beneficiary together, grant full permission for The sweethearts Foundation and any other duly authorized organisation associated with The sweethearts Foundation to make use of the beneficiary’s details which is not limited to their name, surname, age, location, gender, race. The beneficiary grants permission to The sweethearts Foundation to take photographic or videography imagery of the beneficiary with the purpose to be shared on social media, hardcopy media and other related marketing platforms.

The beneficiary further indemnifies The sweethearts Foundation and all other organisations associated with the application, handover ceremony and the use of any and all information received by the beneficiary, which includes but is not limited to, written, verbal, photography or videography, voice recordings, from all prejudice, loss, damage, illness or injury before, during or after the receiving of a wheelchair from The sweethearts Foundation. The beneficiary grants permission to The sweethearts Foundation (and its affiliates or contractors) to record and photograph their involvement (the “Recordings”) and to use such Recordings (including all content on those Recordings) in any media and for any purpose without crediting the beneficiary and without payment and/or compensation to the beneficiary. The Recordings are the sole property of The sweethearts Foundation to use for any purpose, including but not limited to promoting, advertising and marketing activities. To the extent I may own the Recordings or any content in the Recordings; I hereby assign the Recordings and such content to The sweethearts Foundation.

I will hold blameless and indemnify The sweethearts Foundation and all other organisations associated with the activity, should any prejudice, loss, damage, illness or injury occur to me during the above activity. This includes an indemnity against recovery of costs resulting from damage, loss and/or medical conditions or hospitalisation.

I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of claims.

Do you and/or the beneficiary agree to these Terms and Conditions? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service