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Equipment Request Form
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Events
ECFC's Great Big Mini-Golf Classic 2019
ECFC Spring Plant Sale
Alternative Healing Workshop 2019
ECFC Adaptive Toy Workshop II 2019
ECFC Adaptive Toy Workshop 2018
Halloween Huzzah! 2018
ECFC Summer Play Date 2018
Contact Us
Resources
Resources
Home
Our Story
Our Team
Mission & Impact
News
Need Help?
Equipment Donation Program
Inventory
>
Adaptive Seating
Adaptive Strollers
Gait Aides
Standing Frames
Adaptive Bikes & Recreational Equipment
Adaptive Car Seats
Bathing and Toileting
Therapy Equipment
Communication and Education
Orthotics
Miscellaneous
Wheelchair
Equipment Request Form
En español
>
Recepcion de equipos
Donacion de equipos
Donate
Donate
Volunteer
Donate Equipment
Events
ECFC's Great Big Mini-Golf Classic 2019
ECFC Spring Plant Sale
Alternative Healing Workshop 2019
ECFC Adaptive Toy Workshop II 2019
ECFC Adaptive Toy Workshop 2018
Halloween Huzzah! 2018
ECFC Summer Play Date 2018
Contact Us
Resources
Resources
Equipment request Form.
Please fill out and Submit. Thank you!
*
Indicates required field
Name of Person Filling out Request
*
First
Last
Relationship to Child
*
Parent
Legal Guardian
Physical Therapist
Case Manager
Other
Email
*
Phone Number
*
Child's Name
*
First
Last
Child's Date of Birth:
*
Child's Address
*
Line 1
Line 2
City
State
Zip Code
Country
County of Residence
*
Height of Child
*
Weight of Child
*
Other Important Measurements:
*
Ethnicity
*
American Indian / Alaska Native
Asian
Black / African American
Hispanic
Native Hawaiian/Pacific Islander
White / Caucasian
Did you try to get this equipment through insurance or other funding source?
*
Yes, but it was denied by my insurance provider or other funding source.
Yes, my insurance will cover it but I can’t afford the co-payment/deductible.
Yes, but the application process was too long or complicated, so I gave up.
Yes, but the wait is too long and I need the equipment now.
Yes, but I want to try the equipment before ordering it.
No, I didn’t try to get my insurance or other funding source to pay for it. (explain why in the comment section)
No, this is a temporary need for a temporary condition
Other: please explain in the comments section.
Annual Household Income: (This information is for tracking purposes only and will not affect your ability to receive equipment from us.)
*
Less than $20,000
$20,000 - $44,999
$45,000 - $139,999
$140,000 - $149,999
$150,000 - $199,999
Above $200,000
Insurance Type
*
Private
Medicare / Medicaid
None
Item Number(s) That You Are Requesting
*
Will your therapist (PT/OT) be fitting and instructing you in the use of this equipment?
*
Yes
No
Referral Source
*
Friend / Family
Medical Provider
Newslettter / Social Media
Returning Family
School Contact
Web Search
Name of Referring Person
*
First
Last
Email or Phone Number of Person Referring
*
Name of Referring Organization
*
Comments or Other Information:
*
Submit