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Global Outreach to Find Access Resources
Thank you for filling out this form to let us know about your access needs. We will be in touch as soon as possible to discuss what support we can provide.
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* Indicates required question
Name of individual needing equipment
*
Your answer
Name of person filling out this form
*
Your answer
Where does the person live?
Country, State, and/or City
Your answer
How old is this individual?
Your answer
How can we contact you?
*
Your answer
Tell us more about this person's current situation, and what you hope we can help with.
*
Your answer
Mark any/all equipment this person currently has and/or uses:
*
manual wheelchair
power wheelchair
shower/bath chair
feeding chair
adaptive feeding tools (special spoons, forks, etc)
speech generating device
low tech (picture board) to communicate
stander
walker
none of these
Other:
Required
Mark any/all equipment this person does NOT have but may benefit from:
*
manual wheelchair
power wheelchair
shower/bath chair
feeding chair
adaptive feeding tools (special spoons, forks, etc)
speech generating device (talker)
low tech (picture board) to communicate
stander
walker
none of these
Other:
Required
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