Survey - Equipment Donation Survey - The ALS Association Greater Chicago Chapter

Equipment Donation Survey

1.

Please fill out the personal information below:

If you have previously registered, please login here to prepopulate your information.


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP: Required
*	Phone Number: Required
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*2.

Question - Required - Are/Were you or a family member served by the ALS Association Greater Chicago Chapter?

3.

Question - Not Required - If so, which Care Service Coordinator served the family:

Joumana Baroody

Peggy O'Connor

Audrey Scafidi

Gema Ramos

Kellie Branch-Dircks

*4.

Question - Required - Please list any and all equipment that you would like to donate to the ALS Association Greater Chicago Chapter below. Be as specific as possible, especially in regards to how old the equipment is, what condition it is in, and the make and model of the equipment.

*5.

Question - Required - Is the equipment from the VA?

6.

Question - Not Required - Is equipment pick up address different than above? If so, please provide location of pick up:

7.

Question - Not Required - Additional Information/Notes