Medical Equipment Bank Form "*" indicates required fields Transaction* Receiving Equipment Donating Equipment Item/s Donating* Please list Items you are donatingEstimated Value*Please list the estimated value of the item/s you are donatingWheelchair Wheelchair Rollator/Walker with Seat Rollator/Walker with seat Knee Roller Knee Roller Walker Walker Commode Commode (3in1) Shower Chair/Bench Shower Chair/Bench Crutches Crutches Cane Crutches Other Item Other Other Items: Please list other items checked out.Name* First Last Email* Phone*Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date item was received MM slash DD slash YYYY Estimated date of return MM slash DD slash YYYY Consent* I agree to the agreement policy.In consideration for being allowed to borrow the "Equipment" without charge, I, at the recommendation of my physician, will receive the above listed equipment, from Lift Disability Network (the “Medical Equipment Bank”). • I understand and acknowledge that the equipment is on loan to me for my use for the period I have listed above. • I understand and acknowledge that I will inspect the Equipment, prior to taking possession of it, and shall notify Medical Equipment Bank if the Equipment appears to be broken, malfunctioning or otherwise unsafe. I agree not to take possession of the Equipment if it appears to be unsafe. • I will take proper care of the Equipment and return it in good condition. • I understand and acknowledge that I am taking possession of and will use the Equipment “as is” and “with all faults,” and that the Medical Equipment Bank has disclaimed all warranties. There is no warranty that the Equipment will be fit for a particular purpose. I acknowledge that I assume the risks resulting from the loan and/or use of the Equipment. • I will contact the Medical Equipment Bank to negotiate any needed maintenance and repairs. • I understand and acknowledge that the Equipment is not to be lent, transferred, or sold by me. • I will clean the Equipment thoroughly and return the Equipment thoroughly and return the Equipment when no longer needed. All of the above being agreed to, I hereby, for myself my heirs, executors, and administrators, waive, release, discharge, indemnify, hold harmless and agree not to sue the Medical Equipment Bank, their directors, agents, representatives, insurers, employees, or any other persons connected with this program (“the Releases”) on account of any injury, loss or damage, including death and damage to property, caused or alleged to be caused by the Equipment, whether such injury or loss was caused or alleged to be caused in whole or in part by the negligence of the Releases or otherwise. I expressly assume the risk of sustaining bodily injury arising out of the use of provided equipment. Signature* Type Full Name for Signature Δ
