Donation Form for Power Chair To donate a Power Chair please answer as many of the following questions as you can: Date Type of Chair Adult Pediatric Your name Address Address2 City, State, Zip Home Telephone Work Telephone Other Telephone E-mail Approximate Age of Chair Make Model (Number or Name) Batteries good? Or do they need replacing? Is the manual for the chair available? yes no Width of seat High back? yes no Reclining back? yes no Lap belt? yes no Headrest? yes no Oxygen tank holder? yes no Condition Excellent Very Good Good New Chair Value? Any Additional Information? How did you hear about us? May we refer an interested party directly to you? yes no Please contact me first for additional information yes no
To donate a Power Chair please answer as many of the following questions as you can:
Date
Type of Chair Adult Pediatric
Your name Address Address2 City, State, Zip
Home Telephone Work Telephone Other Telephone
E-mail
Approximate Age of Chair
Make
Model (Number or Name)
Batteries good? Or do they need replacing?
Is the manual for the chair available? yes no
Width of seat
High back? yes no
Reclining back? yes no
Lap belt? yes no
Headrest? yes no
Oxygen tank holder? yes no
Condition Excellent Very Good Good
New Chair Value?
Any Additional Information?
How did you hear about us?
May we refer an interested party directly to you? yes no
Please contact me first for additional information yes no