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Apply for Assistance

If you or someone you know is in need of mobility or medical equipment, please fill out the application below. We are honored to help.

Name of Recipient *

Name of Guardian (if applicable) *

Phone Number *

Email Address *

Home Address *

Age of Applicant *

Tell us about the Recipient. We would love to hear your story! *

Please list the Recipient's desired equipment and price points (if known). *

Name of PCP or Therapist *

Are you able to provide a letter of medical necessity from a doctor or licensed practitioner? *

Anything else you would like to share? *

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Elizabeth's Gift is a registered nonprofit organization.
All donations are tax-deductible to the extent allowed by law.

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