Request Loan of Equipment

If you would like to borrow a wheelchair, crutches etc, fill out this form. We will call you to let you know when you can pick it up. * indicates required field
* Name:		If you'd rather call us, leave a message at: (973)-697-2197
Address:
City:
State:
Zip:
* Home Phone:	area code
Work Phone:	area code
* E-mail Address:
What equipment would you like to borrow from the Milton First Aid Squad?	Wheelchair Crutches Walker