Individual Donation of Mobility Aids

"Individual donation" refers to a donation made by an individual or small group of a single or a small number of mobility aids.

If you or your group would like to supply a single or a small number of the specified mobility aids which are appropriate for the Haiti Mobility Aid Relief Effort, please complete the following form.

Once you have submitted the form online, please also print the form and include it in the shipment of your donation.

DONOR INFORMATION

Prefix:

* First Name:

* Last Name:

Organization:

* Street Address 1:

Street Address 2:

* City:

* Country:

* Region:

* Zip Code:

* Email:

* Re-enter mail:

Cell Phone Number:

Home Phone Number:

Work Phone Number:

Comments:

How did you
learn about this?

MOBILITY AID INFORMATION

Please select the product(s) and quantity(s) that you intend to donate

Crutches

Walkers

Wheelchairs

Adult Crutches

Adult Walkers

Adult Wheelchairs

Pediatric Crutches

Pediatric Walkers

Pediatric Wheelchairs

SHIPPING INSTRUCTIONS

Package all donated products appropriately and ship to:	Center for International Rehabilitation 350 West Mart Center - C2 level Suite 115 Chicago, IL 60654 312.280.4970
If you have any questions or concerns, please feel free to write to us at support@iconsinmed.org