Local & Domestic Giving Program 1st Time Applicant

Local & Domestic Giving

First Time - Applicant Registration Form
MedWish Medwork' Local and Domestic Giving Program aims to connect vulnerable populations in need of medical supplies with the vast inventory MedWish Medworks maintains in its warehouse, through vetted agencies that help individuals with medical necessities, working together to promote their improved health and increased quality of life.

HOW WILL THE PROGRAM WORK?

Through its Local & Domestic Giving Program, MedWish Medworks will partner with local health and human service organizations/agencies to match its inventory with the needs of the community. Through this application process, MedWish Medworks will accept requests for supplies. MedWish Medworks will then review the request, match its inventory to the identified need, and organize a pick-up. Supplies can be picked up by either the referring non-profit organization or the recipient once an appointment has been established with the coordinator of Local & Domestic Programs. Due to their nature, certain medical devices can only be distributed directly to the sponsor organization to ensure proper training and usage.

The program is open to all eligible social agencies and non-profit organizations who act as a sponsor to verify the medical and financial needs of the recipients, as we aim to provide supplies and equipment to those who cannot obtain them through insurance or afford them otherwise. At this time, the original fee for service for this program has been covered by our generous donors. This is subject to change at any time and will be communicated to you in the event that a fee is reinstated. Shipping costs will not be covered and will be the responsibility of the recipient.

ELIGIBILITY:

For an organization/agency to be considered to receive donations (as part of MedWish Medworks' Local & Domestic Program), they must:

- Be a U.S. social service agency or not for profit organization.

- Must not use donated surplus for sale or as a means for profit. The recipient organization must vet the needs of those being served and distribute the donated supplies directly to the recipient(s)/individual(s). If reinstated, the fee for service charged by MedWish Medworks is not allowed to be passed on to the recipient(s)/individuals.

- Must provide timely and detailed feedback once donations are received (i.e. pictures, narrative) that can be used for program management review, grant reporting, on our social media posts, or other publications.

- Must demonstrate a commitment to serving all people regardless of age, race, gender, sexual orientation or religious beliefs.

For more information, please contact MedWish Medworks at domesticaid@medwish.org or call 216.692.1685 x22.
PARTNER AGENCY FORM

Please be sure to review the application instructions before proceeding.

Once MedWish Medworks receives the application, we will follow up with you to discuss next steps or to request additional information.

Please note that you will be required to update and complete a new application every 5 years.
Official name of organization/program: *
LOGISTICS AND PROCESSING/HANDLING FEE - All orders require the sponsoring organization to either have someone pick up the items from our warehouse at 1625 E. 35th St. in Cleveland or pay for shipping. Does your organization have the ability to pick up these donations or pay to have them shipped?*

YESNO
Sponsor Organization Type:*

SchoolSocial AgencyFaith-base groupOther
Primary Administrative Contact*

First NameLast Name
Title*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Website
Phone Number*

Area CodePhone Number
Facebook Address
Primary on-site contact (if different from above)

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
PROJECT NARRATIVE*
How did you hear about this program?*

I've volunteered at MedWish beforeInternet searchI was referred by someoneOther
If you were referred to MedWish Medworks by a person or organization, please let us know who:
ORGANIZATIONAL INFORMATION

Please describe the mission, history and programs of the organization/agency. Include information about the organization’s structure, staff and consumer numbers.
Mission, history and programs:*
EIN/Tax ID Number:*
501c3 Letter of Determination*

Browse Files

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Approximate number of staff:*
Approximate number of consumers served annually:*
Approximate number of consumers that will benefit from this request:*
Please indicate the race(s) of those your organization serves and the percent makeup of the population. *
Please indicate the predominant reason medical support is needed by those your organization serves.*
What is the economic status of those you serve?*
DESCRIPTION OF NEED

Please describe the community or population the organization/agency serves, including leading health issues and other information relevant to your program or project.
Need description*
How will the requested supplies and equipment support these needs?*
How will your organization vet the needs of those being served?*
Please list the requested supplies, sizes, and quantities:*
LOGISTICS AND PROCESSING/HANDLING FEE - Some items require the sponsoring organization to pick up the items directly. Does the organization have the ability to pick up these donations?*

YESNO
Who will be responsible for paying the processing/handling fee?*

Organization/agency contact listed on this formSponsor organization – If so, please notify the MedWish Rep.Other
IMPORTANT:

MedWish Medworks does not distribute medication. Prescriptions for medical supplies are not needed for distribution. Please DO NOT send prescriptions to our staff.
WISH LIST

Please check any items your organization desires to have and we’ll work with you to prioritize, set quantities and sizes, and identify alternatives for requested items that are not available.

Remember: This list is an example of items commonly available in our inventory, but not a guarantee that any one item is available at this time. We will do our best to meet your needs to the best of our ability, and will work with you to substitute items or adjust your order when necessary.
Select needed equipment:

Crutches - $10eaIV Pole - $10eaNebulizer machine - $20eaOver-the-bed tray tables - $20eaShower chairs - $10eaWalkers (collapsible) - $10eaRollators - $25eaManual wheelchairs - $40eaBariatric Bed - $225eaHome health bed - $150eaWheeled lab stool - $10eaHoyer Lift - $40eaDisposable supplies - $2/lb.Specialized item
Please include any information about sizes, quantities or details for items if you know them. If there are any additional items you wish to request that were not on the list, or if you have any comments about the items you have requested, please briefly describe here:
REPORTING RESPONSIBILITY

Feedback is a vital element of the Humanitarian Aid program at MedWish Medworks. It allows us to continually improve our services and programs to better support health care. It also helps us secure continued financial support, donated supplies and volunteers. A feedback survey will be due back to MedWish within 30 days of your successful receipt of goods.

By submitting this application, you consent to permitting MedWish Medworks to track and share information about the organization/agency for quality improvement, communications and fundraising purposes. Information included in the application as well as in the 30-day feedback report may be used for these purposes.

If for any reason your organization/agency cannot consent to publicizing details about your project please inform the MedWish Medworks representative. MedWish Medworks does not wish to put any recipients at risk and will respect confidentiality requests; however, we will require feedback from all recipients for internal record-keeping and quality improvement. Failure to send complete and timely feedback report may disqualify the recipient organization/agency from future eligibility.
Name of person responsible for completing feedback report: *

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
CONSENT AND LIABILITY RELEASE

Legal Statement

The medical supplies, equipment and materials available from MedWish Medworks are items received from healthcare facilities, providers, manufacturers and/or distributors in the United States – many of which would otherwise have been discarded. These materials are being made available strictly on an "as is" basis for the use by humanitarian relief organizations and social agencies. MedWish International and the donor facilities do not represent, warrant or imply that such materials are fit, appropriate, free of defects, sterile, pure or suitable for any purpose.

Each recipient organization/agency and recipient facility assumes full responsibility for making an independent determination of the appropriateness of each item of donation before using it. By submitting an application for the receipt of donated supplies, each organization/agency and recipient facility releases MedWish International, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials.

I have read and understand the above statement releasing MedWish Medworks, its officers, trustees, employees and donors from all responsibility, claims, costs and liability associated with the donated materials. Submission of this form is an agreement of the above terms, however, you may be asked to fax/mail a signed copy of this agreement in the future.

Additionally, by checking the box below, you are confirming that you will not be working with any person or entities that are under trade or financial sanctions under the laws and regulations of the United Nations, the United States or any other jurisdiction that is applicable to the Rights and Services to be provided.
Applicant's full name*

First NameLast Name
Organization/Agency name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date*

MonthDayYear
Date
Signature

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