Durable Medical Equipment Loan Request

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On Campus Mom Foundation

Email *

YYYY

Requesting Party's Name: *

Is the requesting party a student or parent? *

Parent

Student

Other:

Requesting Party's Phone Number: *

Name of Person Receiving Equipment: *

Location of Person Receiving Equipment: *

Telephone Number of Person Receiving Equipment: *

Equipment Requested:

Aluminum Crutches

Knee Scooter

Rolling Walker

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Duration of Equipment Loan Requested:

The On Campus Mom Foundation, Inc. will facilitate delivery of the item(s) listed above to the dorm desk or apartment office location as indicated as the delivery location on this form if the equipment requested is in stock and available.

The On Campus Mom Foundation, Inc. bears no liability in relationship to equipment malfunction or injury resulting from improper use.

I agree not to hold the On Campus Mom Foundation, Inc. liable for any negative outcome that may result from equipment malfunction or improper use of the equipment

Return of Loaned Equipment: *

I agree to return requested loaned equipment to the On Campus Mom Foundation, Inc. in good operable condition at the end of the requested loan period. Student will make contact with the foundation in reference to an agreeable pickup time and location.

Additional Comments:

A copy of your responses will be emailed to the address you provided.

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