sweethearts Foundation Wheelchair Request
Please fill in this form if you or somebody you know of requires a wheelchair, we promise to help our very best and will try to help in as short a time as possible but cannot always guarantee a quick response due to the availability of "Tops and Tags" collections and donors...
Email address *
Name and Surname *
Provide Name and Surname of person needing the wheelchair
Your answer
Gender *
This information is required for reporting purposes as per the EEA1 form...
Ethnic Origin or Race *
This information is required for reporting purposes as per the EEA1 form...
ID Number or Birth Certificate Number
Provide the identification of the person needing the wheelchair
Your answer
Date of Birth of person needing a wheelchair *
This information is required for reporting purposes as per the EEA1 form...
MM
/
DD
/
YYYY
Name and Surname of Guardian, Family Member or Friend
If the person needing the wheelchair is under 18 years old or not able to request their own wheelchair and you are helping please fill in your details
Your answer
ID Number of Guardian, Family Member or Friend
Provide the identification of the guardian or friend that is assisting the person needing a wheelchair
Your answer
Cell Number *
Your answer
Address *
Your answer
Email Address *
Your answer
Wheelchair Specifications *
What type of wheelchair are you requesting, adult or child sized wheelchair?
Your answer
Documents required to request a wheelchair
Have you provided us with the following documents? Please email the scanned documents to sweethearts@sweetheartsfoundation.org for us to start working on your request immediately, however we also require original certified photocopies of the documents below by a Commissioner of Oaths...
What is your name? *
What is the name of the person filling out this form?
Your answer
What are your contact details? *
Please give us your email address and contact number so that we can contact you if we have trouble reaching the wheelchair beneficiary.
Your answer
Other details the sweethearts need to know about?
Your answer
A copy of your responses will be emailed to the address you provided.
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