Equipment Loaner Program Form

SMILE Mass has several pieces of equipment for families to borrow and take anywhere with them. Our current inventory includes: 10 floating beach wheelchairs, high performance running strollers, a Hoyer lift, a portable ramp and bath chair. Please download, print, fill out, & bring a copy of the waiver with you upon the day of pickup, Along with filling out the form below so we can get in contact with you as soon as possible!

Equipment Loaner Form

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
How did you hear about SMILE Mass?*
What piece(s) of equipment would you like to borrow?*
Requested pick up date*
MM slash DD slash YYYY
Requested return date*
MM slash DD slash YYYY
Do you need delivery? (additional fee)
fee is based on travel time from Sudbury - details will be provided upon receipt of request. If the delivery address is different from above, please provide exact delivery address below
Questions/Comments:*
If you could tell us where you are going, it will help us with pick-up/return planning
Birthday
MM slash DD slash YYYY
Have you used our program before?

Special Thanks To Our Sponsors:

“This organization is doing so much for so many families. I used their beach chair loaner program to get down to the beach with my family for the first time in over a decade. I didn’t really realize how much I missed spending time "strolling" at low tide and swimming in the ocean. There aren’t enough words of gratitude to express how this organization has changed my life.”

Deb Fowler via Facebook