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Assistance Form


To provide our funders with the most accurate information about the people whom we serve please complete the following questions.


Note: How you answer will never prevent you from accessing medical equipment from CCH.

What Kind of Medical Equipment Will You Need?

I acknowledge that the above-identified equipment was inspected by me, or the person responsible noted above and at the time I received the equipment it was clean and in good condition. I agree that I will return the equipment in the same condition when my (or my childs) present physical need no longer exists. I will not permit this equipment to be transferred to another person under any circumstances, and while this equipment is in my possession, I will notify you of any change of address for me. I will not take this equipment out of the area served by Clinics Can Help. I hereby release and hold harmless Clinics Can Help, its members, agents, or employees from any claim by me, or any person acting for me or on my behalf for any loss, expense, or damage, including but not limited to general, specific, incidental, or consequential damages, of any kind or nature whatsoever arising from this equipment or its use. I agree that Clinics Can Help, its members, agents, volunteers or employees have made no representation of any kind whatsoever expressed or implied, to me with regard to the condition of the equipment provided or as to the use to which the equipment is to be put. I also give Clinics Can Help permission to take my photo and to use it in any and all promotional venues.

Words from Those We've Helped

“You took the time to care by asking about my son Casey's condition. Then with your knowledge you began to GIVE MORE than I asked for. You said you will need this and that etc ... I was both overwhelmed with ALL that was NEEDED and How Much this is going to COST? I pulled out my check book and asked How Much? You said Nothing!! I cried, no one in my life has ever cared to offer us help and for free Clinics Can Help does help!!!!”

-Barry Bicknell

Words from Those We've Helped

“You took the time to care by asking about my son Casey's condition. Then with your knowledge you began to GIVE MORE than I asked for. You said you will need this and that etc ... I was both overwhelmed with ALL that was NEEDED and How Much this is going to COST? I pulled out my check book and asked How Much? You said Nothing!! I cried, no one in my life has ever cared to offer us help and for free Clinics Can Help does help!!!!”

-Barry Bicknell