Request Adapted Equipment

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:

“SMILE Mass offered the Ocean Park, Maine community with a beach wheelchair in 2017. IT was used all summer long and people loved the freedom it gave them to see and experience the beach. This donation is a way for us to continue to say thanks. Your work is very important!”

Gerard Gosselin