Equipment Donation Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)How would you like to be contacted?(Required)PhoneEmailText1. Are/were you or a family member served by ALS United Mid-Atlantic? If so, name of patient?(Required)2. Please list any and all equipment that you would like to donate to ALS United Mid-Atlantic below. Be as specific as possible, especially in regards to how old the equipment is, what condition it is in, if the batteries work, and if possible, the make and model of the equipment.(Required)3. Is the equipment pick-up address different than the above? If so, please provide the location of pick up.4. Additional InformationCAPTCHA