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Needs Request Application

FUND IT FORWARD operates on a pay it forward model, which means that volunteers fundraise for future needs. Families are strongly encouraged to fundraise before requesting a gift of medical or adaptive equipment for their child. Each applicant is reviewed based on a number of criteria which includes fundraising efforts. Successful volunteer fundraising events determine how many families - like yours - FUND IT FORWARD can assist.

* = required fields



Patient (Child) Information

Name of patient (child) *:

Date of birth (MM/DD/YYYY)*:

Diagnosis *:

Name of equipment *:

Enter type (ie. bed, monitor) and if possible also brand

Parent / Guardian Information

Name of parent / legal guardian *:

Address *:

City *:

State *:

ZIP code *:

Phone number *:

E-Mail address *:


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(Please make sure to check out our FAQs)

How did you find us?

 Google, searching for:
 Personal recommendation from:
 Link from other Website:
 Article/Ad in (magazine):
 Special event (place/date):

Enter verification code *:




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