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           

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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