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:

“What a wonderful cause and I would be proud to donate! I had a cousin who was two weeks older than I who died of MS in 2002, and we always were inseparable at the beach at Ocean Park when growing up. When she got so bad and was confined to a wheelchair, her family would bring her to a rental in Kinney Shores but there was no way to get her near the beach or ocean. To think of so many children who are missing out on the beach experience is heartbreaking. We’ll donate online and wish you the best!”

Love, Ellen & Steve