Survey - Equipment Donation - ALS United Greater Chicago

Equipment Donation

1. Please provide your information:

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2. Field Is Required Are/Were you or a family member served by ALS United Greater Chicago?

3. If yes, which Care Service Coordinator served the family?

4. Field Is Required Please list any and all equipment that you would like to donate to ALS United Greater Chicago below. Be as specific as possible, especially in regards to how old the equipment is, what condition it is in, and the make and model of the equipment.

5. Field Is Required Is the equipment from the VA?

6. Is the equipment pick-up address different than the above? If so, please provide the location of pick up:

7. Additional Information: