This program will facilitate the exchange of durable medical equipment and unused supplies such as standers, specialty walkers, feeding pumps, positioning devices, formula, diapers, oximeter, etc. If you have items available to donate, please follow these steps before completing the Equipment Exchange Program Form:

Send an email to info@krabbeconnect.org to inform us of the items up for donation.
Within 2-3 business days of your email to info@krabbeconnect.org, someone from KrabbeConnect will reach out by email to set up a call. During this call, we will gather information on the size and type of items being donated.
KrabbeConnect will conduct outreach on the items donated. Once an individual(s) in need of the item(s) donated is identified, KrabbeConnect will reach out to their shipping vendor to obtain an estimate.
Once the estimate has been received and approved by the Patient Assistance Program Committee, KrabbeConnect will facilitate the exchange of the equipment (from the individual donating the equipment to the individual receiving the equipment) and pay for the shipping costs.
If KrabbeConnect is unable to identify an immediate need for the equipment and/or supplies by another individual impacted by Krabbe disease, the equipment/supplies will remain in the custody of the owner. KrabbeConnect does not have a warehouse to maintain an inventory of donated equipment.
IMPORTANT: If you plan to claim your donated equipment for tax purposes, please be sure to locate a company in your area that can provide you with a certified estimate on its value. KrabbeConnect cannot provide this type of service. The completed equipment exchange form should be attached to the value statement when you file your taxes.

Application to Receive

Please Note: These programs are for patients and their families who reside in the United States. KrabbeConnect’s ability to help outside of the US is limited. However, we will review and consider all requests.

Equipment/Supplies Exchange Program

The Equipment/Supply Exchange Program connects Individuals Donating Products to Individuals Receiving Products.
Equipment availability is based solely on donations.
Equipment varies based upon what has been donated and what has been shipped, so check back often!
Supplies are not distributed from a central warehouse; they are shipped from Individual to Individual.
KrabbeConnect reserves the right to decline an application due to shipping costs or lack of funding for this program.

"*" indicates required fields

Equipment/Supplies Exchange Program

The Equipment/Supply Exchange Program connects Individuals Donating Products to Individuals Receiving Products.
Equipment availability is based solely on donations.
Equipment varies based upon what has been donated and what has been shipped, so check back often!
Supplies are not distributed from a central warehouse; they are shipped from Individual to Individual.
KrabbeConnect reserves the right to decline an application due to shipping costs or lack of funding for this program.

Equipment Receiver Information

Is your patient a KrabbeConnect Hero?*

Yes

Learn more about KrabbeConnect Heroes.

This program requires the patient to be a registered KrabbeConnect Hero – Sign Up and then return to this page to continue your application.

Name of patient receiving the equipment*

First Last

Please provide a document with Krabbe disease diagnosis of the patient

Max. file size: 50 MB.

Name of Caregiver or Guardian*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Alternate Phone

*Equipment (items being received) – ITEM – QUANTITY – WEIGHT/BOX SIZE (H,W,L)

A list of items, to the best of your knowledge, you agree to receive from donor. If there is a time that the equipment is no longer needed by the patient, you agree to contact KrabbeConnect’s Patient Assistance Program so that it can be offered to other Krabbe disease patients for their use.

Pictures

We would love to see the recipient of the equipment using in it. Please sign the consent form below for any pictures you may send us in the future.

Informed Consent

Photography, Video, Audio Recordings

I (the undersigned individual) hereby grant full permission to KrabbeConnect and its employees, legal representatives, agents, representatives, successors, assignees and assigns (collectively, the “Authorized Parties”) to take my or my minor child(ren)’s photograph, videoclip or sound recording and to use or reproduce such items, as well as my or my minor child’s name and any other information provided by me about me or my minor child(ren) (collectively referred to as the “Materials”) for any purpose in the Authorized Parties’ sole and exclusive discretion. I represent that I am 18 years of age or older. I understand that the Authorized Parties may adapt, modify, reproduce, distribute, publish, display and create derivative works of the Materials and that the Authorized Parties have no obligation to compensate me in any way for any use of the Materials. I understand and agree that the Authorized Parties are and will be the exclusive owner of all right, title and interest, including copyright, in works of authorship which they create and which incorporate the Materials. I expressly release the Authorized Parties from any and all claims which I have or may have in the future for invasion of privacy or any other cause of action arising out of the uses of the Materials herein granted, even if the usage of the Materials is objectionable to me.

I represent that if this Informed Consent relates to my minor child(ren), I am the parent or legal guardian of the below-named minor child(ren).

Name of Minor Child(ren) (if applicable)

Name

First Last

Informed Consent Signature

Certification

By signing this form, I certify that:

The patient listed above has been diagnosed by his or her medical provider with the condition listed above.
The patient is currently being treated for this condition by his or her medical doctor
The patient’s diagnosis and treatment are managed by his or her medical provider and the receiver recognizes this is a charitable program to assist families in obtaining equipment that may help support the patient’s medical condition
The receiver (authorized caregiver/guardian) and or patient, does not hold KrabbeConnect accountable for the condition of the equipment or training to properly use the equipment. The receiver (authorized caregiver/guardian) and or patient will refer to their medical provider for information and training.

Formal Disclaimer: I do not hold KrabbeConnect or any of its subsidiaries responsible for any mishappenings that could or might occur as a result of trying to facilitate the shipment of the equipment to a family and/or patient in need. KrabbeConnect operates this program to exclusively assist patients and/or caregivers in donating no longer needed medical equipment to a family in need of medical equipment. The donor and the receiver of the equipment acknowledge this upon the signing of this document.

Receiver's (Authorized Caregiver/Guardian) Signature*

Recevier's (Authorized Caregiver/Guardian) Printed Name*

Date*

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