Equipment & Supply Exchange Form

First Name

Last Name

Mobile Phone

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

Mailing Country

Please select the Leukodystrophy that affects your child or select Other if your child does not have a Leukodystrophy.

If you selected Other or Unspecified, please explain.

Affected Child's First and Last Name

Are you donating item(s) or requesting item(s)?

DonatingRequesting

Item You are Donating

Name of Item

Brief Description

Value, Brand, Make, Model, Weight, and Dimensions

Approximate weight and height of child when they used the item

Please add up to three photos from different angles of the item you are donating.

Please provide any additional information that might be helpful

Item(s) You are Requesting

Name of Item

Brief Description

Cost of Item, Brand, Make, Model, Weight, and Dimensions, etc. (if known)

Please provide a detailed explanation of your attempts to acquire this item for your child.

Please explain how this item will improve your child's quality of life.

Approximate weight and height of your child

Please provide any additional information that might be helpful about this item and/or your child.

Requests

Should my request be fulfilled, I agree to the following: I will provide testimonial statement and photo of my child using their gift (if possible) to Hunter's Hope for publicity purposes. Once this item is no longer used, I will donate it back to the Equipment and Supply Exchange program for use by another family (when applicable).

YesNo

I hereby state that the provided information is accurate to the best of my knowledge. Should this request be granted, I give Hunter's Hope permission to use any photos or statements regarding this request.

YesNo

When you are finished, please click on the Submit button below.

Thank you!

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