Equipment & Repair Request

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Changing The Lives Of Mobility-Challenged Children In Need

We don't let mobility keep a child from reaching their full potential.

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If you are the parent/legal guardian of a child with a disability through the age of 21, living in the USA, that is in need of a wheelchair, stander, gait trainer, or wheelchair repair and seeking a donation of one, send in the following information for consideration:

Equipment & Repair Request

Child's Location:*

Parent or Legal Guardians Name:*

Contact E-mail Address:*

Contact Phone Number(s):*

Child's Name:*

Child's Age:*

Child's Condition:*

Insurance Type:*

Has Insurance Been Denied?:*

Yes No

Details / Comments?:*

Can Wheelchair Be Presented In Public (To Increase Charity Awareness)?:*

Yes No

Equipment Requested (Check All That Apply):

Manual Wheelchair Powered Wheelchair Gait Trainer Stander Repair Accessory Other

Please indicate equipment requested:*

Can you pick up from West Palm Beach Area?:*

Yes No

School Attending?:*

More information (Your Story):*

How Did You Hear of Chariots Of Love?:*

Please upload the first photo of the candidate for our records:*

Please upload the second photo of the candidate for our records (optional):

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PO Box 541224
Lake Worth, FL 33454
chariotsofloveusa@gmail.com

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