AccessAbility First Foundation - Medical Closet Request Form 
Please fill out this form as detailed as possible. An incomplete request will not be answered or fulfilled.
A representative will attempt to contact you via phone, text, or email for further information regarding your request before approval-- after 2 attempts, the request will be cancelled. If a recipient fails to meet for a scheduled pick up time, all items will be returned to the closet program and will not be held. Otherwise, all items are always first-come, first-served. AccessAbility First Foundation will also do our best to fill wait list requests in order received as donations come in. You may request items once per quarter.


For further questions/concerns, please email jordandiibon@accessabilityfirst.org.
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Email *
What item are you requesting? BE VERY SPECIFIC, this will help us insure your needs are met promptly. Limit each form to 3 items, if you need more than 3 items please fill out another form. Please include sizes and/or measurements. *
What is your address? Invalid or incomplete addresses will not be accepted.  *
Reason for assistance  *
Phone Number *
Are you within 30 miles of San Angelo, Texas?  *
Annual Household Income (this doesn't disqualify you, as it is for data purposes only) *
Number of Household Members  *
TERMS AND AGREEMENT - 

1. I am aware that The Closet Program is supplied through donations and that my request may not be fulfilled within a specific time frame. All requests are fulfilled at the discrepancy of AccessAbility First Foundation staff.
2. I am aware that equipment and/or supplies I receive from The Closet Program are gently used. I am aware that AccessAbility First Foundation is not responsible for any broken equipment or missing pieces. I am aware that AccessAbility First Foundation is not responsible for any potential injuries that could be caused by equipment and or supplies. I release all liability from AccessAbility First Foundation. 
3. I am aware that selling and profiting from donated medical equipment and supplies is considered fraud. If there is any reason to believe such activity I will be disqualified from assistance from AccessAbility First Foundation. 
 *
I authorize AccessAbility First Foundation to use photos of me for marketing, advertisement, and grant writing purposes. *
First & Last Name  *
Is this item for a child or adult?  *
Choose size and number per color
How did you hear about us?  *
Required
A copy of your responses will be emailed to the address you provided.
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