ALS Association DC/MD/VA Chapter

Medical Equipment Loan Closet Donation Form

Please help us learn more about the equipment you would like to donate by answering the questions below. After you submit the form, the Loan Closet Program Director will be in contact within one to two business days to confirm your item(s) eligibility.

First Name *

Last Name *

Email *

Phone Number *

Street Address *

City *

State *

Zip Code *

Are you an individual/family served by the ALS Association DC/MD/VA? *

Are you donating a Power Wheelchair? *