In this section, please provide the details requested for the person who benefits from this request.
Please indicate which symptoms the Recipient suffers from as a result of their diagnosis. Please check all that apply.
If you selected "Other" and/or if you would like to elaborate on the Recipient's condition, please use the comments box below.
In this section, please provide the requested details on the Recipient's diagnosis, including the contact details of the physician who diagnosed the Recipient.
Please upload physician signed diagnosis verification.
In this section, please describe the item being requested. Including the company/store in which it’s being purchased, purchase price, and item number.
Please provide the reason for the item request; how it will benefit the Recipient and help with limitations caused by his/her diagnosis.
Please provide the shipping address where ADOAA will ship the item.
PROGRAM TERMS AND CONDITIONS
By completing this form, I acknowledge and provide my consent to receive future communications from ADOAA. I understand that I may be requested to participate in an interview with ADOAA board members to better understand my request.
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I acknowledge that I must be at least 18 years old to submit an application on Recipient’s behalf. This application is the first step of the Give Back process and is not a confirmation of eligibility for a give back. A physician diagnosis must be submitted with the application for consideration. Funding availability and item request approval is subject to ADOAA board confirmation. Upon approval, you must sign and agree to ADOAA’s Release of Liability within the specified time. ADOAA will then order, pay and ship the requested item to the Approved Applicant. Approved Applicants will be listed on ADOAA.org. ADOAA is not responsible for Approved Applicant’s tax compliance, if applicable. No purchase or donation is necessary to participate. A purchase or donation will not increase your chance of approval. Void where prohibited.
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By submitting this application, you waive your rights to bring any claim, action, or proceeding against ADOAA and its agents, employees, and representatives (“Released Parties”) in connection with the Give Back; and to forever agree to release and defend, indemnify and hold harmless the Released Parties from any and all claims, lawsuits, judgments, causes of actions, fines, penalties, liability costs and expenses (including, without limitation, reasonable outside attorneys’ fees) that may arise in connection with your participation in the Give Back (including the item requested).
