BIKUR CHOLIM GMACH - MEDICAL EQUIPMENT FREE LOAN

Bikur Cholim's Medical Equipment Gmach loans out wheelchairs, walkers, crutches and various types of medical supplies free of charge to patients and families of all ages.

EQUIPMENT - CHOOSE UP TO FOUR ITEMS

Requested Item 1

Requested Item 2

Requested Item 3

Requested Item 4

Date of pick-up from our office:

Date expected to return items to our office:

Self

Salutation

First Name

Middle Initial

Last Name

Mobile Phone

Home Phone

Spouse

Salutation

First Name

Middle Initial

Last Name

Mobile Phone

Address Line 1

City

State

Zip Code

Who referred you to Bikur Cholim?

Enter "none" if none.

What is your Synagogue Affiliation?

Enter "none" if none

PERSON USING ITEM(S)

First Name

Last Name

Date of Birth

TERMS AND AGREEMENT

Please carefully read and agree to the following terms. By doing so, you agree that failure to adhere to these terms may result in the loss of your entire deposit and or a $500 restocking fee.

I understand that a refundable credit card security deposit is required on items loaned prior to picking them up from Bikur Cholim.

I agree

I understand that if any item is needed beyond the date listed on the request form, then I must reach out to Bikur Cholim for their approval.

I agree

I understand that I must safeguard items from any misuse and never leave items outside exposed to the elements regardless of the weather.

I agree

I understand that all items are loaned in clean operable condition and that I am required to return all items in the same condition in which they were picked-up.

I agree

I understand that anyone who picks up and or uses loaned items waives and releases Bikur Cholim from all liability and/or claims for injuries sustained and/or caused while using or in possession of loaned items and indemnifies Bikur Cholim from any claims and all potential liabilities that may arise from use or non-use of loaned items.

I agree

I understand that once any loaned item is no longer in use, I am to call Bikur Cholim at (323) 852-1900 to schedule its soonest return to their office and that items cannot be returned without first scheduling an appointment subject to Bikur Cholim’s availability.

I agree

I understand that no returned item is to be handed over to non-Bikur Cholim personnel, nor left unattended inside or outside of Bikur Cholim premises.

I agree

I understand that once I’ve submitted this form, then I must call Bikur Cholim at (323) 852-1900 to confirm receipt of my request.

I agree

By submitting this form, I agree that failure to adhere to the above terms may result in the loss of my entire deposit and or a $500 restocking fee on my credit card.

I agree

Agreement Date

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