Alternatives in Motion

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TAPSHOE PRODUCTIONS
CEDAR TREE PUBLISHING

CONTACT US

Donation Form

Complete this form to donate equipment or money—we accept either one gratefully. When we receive this form, one of our representatives will contact you for details.

First Name*

Last Name*

Address*

Address

City*

State*

Zip*

Daytime Phone

Evening Phone

Mobile Phone

Email*

Confirm Email Address*

Equipment Donations
(check one per form)

	Manual Wheelchair
	Power Wheelchair
	Scooter
	Walker

For the piece of equipment you want to donate, please answer the following questions:

Year
Make
Model

Condition of equipment
(check the one that best describes the equipment you wish to donate):

	New
	Barely Used (less than 3 months)
	Excellent Condition but used for 3-6 months
	Used for over 6 months and needs repairs (Specify what repairs are necessary)

Wish List donations
(current needs)

	Computer (MacIntosh)—new
	Printer (new or gently used in excellent condition)
	Money

*Required field