Request Form - CARE PROJECT - Easterseals Central Alabama

CARE Request

Today's Date(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Alternate Phone

Can someone leave a message for you?(Required)

Please let us know if voice mail or a text would be better.

Voice Mail

Text

Updates, News & More(Required)

Would you like your name to be added to an email listing to receive Featured Items for the Month, Upcoming Events, or updates on the CARE Project and other Easter Seals Central Alabama Programs?

Yes

Recipient's Date of Birth(Required)

Recipient's Ethnicity(Required)

Hispanic

African American

Caucasian

Recipient's County(Required)

In which Alabama county does the recipient reside?

Recipient's Primary Disability(Required)

Recipient's Secondary Disability

Please provide height, weight & width.

Only needed if requested item may have size limitations.

What item are you requesting today?

Do you have a prescription order from a doctor?(Required)

Waiting List(Required)

If the item you are requesting is not in stock, do you want to be placed on a waiting list?

Yes

How did you hear about CARE?

Referrals

If you have been referred by another agency, Hospital/Doctor’s Office or other Health Organization, what is the name and phone number for that organization so that we may properly fill your request?

Please be patient. A member of the CARE PROJECT will reply to your request as soon as possible. If this is an emergency, contact your local Durable Medical Equipment Supplier. CARE is not an emergency program. Staff and time are limited and requests may take time depending upon availability. Thank you!

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Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Easterseals Central Alabama

Request Form – CARE PROJECT

CARE Request

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