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Request Form – CARE PROJECT
Request Form – CARE PROJECT
CARE request
Today's Date
*
Name
*
First
Last
Email
*
Phone
*
Alternate Phone
Can someone leave a message for you?
*
Please let us know if voice mail or a text would be better.
Voice Mail
Text
Updates, News & More
*
Would you like your name to be added to an email listing to receive Featured Items for the Month, Upcoming Events, or updates on the CARE Project and other Easter Seals Central Alabama Programs?
Yes
No
Recipient's Date of Birth
*
Recipient's Ethnicity
*
Hispanic
African American
Caucasian
Recipient's County
*
In which Alabama county does the recipient reside?
Recipient's Primary Disability
*
Recipient's Secondary Disability
Please provide height, weight & width.
Only needed if requested item may have size limitations.
What item are you requesting today?
Do you have a prescription order from a doctor?
*
yes
no
Waiting List
*
If the item you are requesting is not in stock, do you want to be placed on a waiting list?
Yes
No
How did you hear about CARE?
Referrals
If you have been referred by another agency, Hospital/Doctor’s Office or other Health Organization, what is the name and phone number for that organization so that we may properly fill your request?
Please be patient. A member of the CARE PROJECT will reply to your request as soon as possible. If this is an emergency, contact your local Durable Medical Equipment Supplier. CARE is not an emergency program. Staff and time are limited and requests may take time depending upon availability. Thank you!
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