Local & Domestic Giving Program 1st Time Applicant

Local & Domestic Giving Program 1st Time Applicant
Local & Domestic Giving

First Time - Applicant Registration Form
LOCAL & DOMESTIC GIVING PROGRAM

Since 1993, MedWish has worked to transform discarded medical supplies and equipment in the US into humanitarian aid for health systems and providers in the developing world. Today, MedWish is poised to expand programming so that Northeast Ohio residents in need can also benefit from salvaged medical supplies that MedWish procures from hospitals and manufacturers in its Cleveland-based world headquarters.

Throughout the years, MedWish has witnessed first-hand the local and domestic need for access to medical supplies, and in response to the persistent need for access to medical supplies and equipment in Cleveland and other cities, MedWish launched its Domestic Giving Program.

The program aims to connect vulnerable populations in need of medical supplies with the vast inventory MedWish maintains in its warehouse, through vetted nonprofit organizations and social service 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 ithis program, MedWish partners with nonprofits and social service agencies to match its inventory with the needs of low-income individuals and seniors. Through a formalized application process, MedWish will accept requests for supplies from the agencies. MedWish will then review the request, match its inventory to the identified need, and organize a delivery or pick-up.

The program is open to all eligible social service agencies, and nonprofit organizations and their consumers. Applicant organizations will pay a handling fee (fee for service) to offset a portion of MedWish’s costs to procure, repurpose, and distribute its medical inventory, and the program will be administered by MedWish’s professional staff.

ELIGIBILITY:

For an organization/agency to be considered to receive donations (as part of MedWish’s Domestic Giving Program), they must:

- Be a nonprofit organization or social service agency.

- Setup an appointment with a MedWish representative.

- Must not use donated surplus for sale or as a means for profit. The recipient organization must distribute the donated supplies directly to the recipient(s)/individual(s).

- Must demonstrate ability/commitment to paying MedWish's processing/handling fee.

- Must provide timely and detailed feedback once donations are received.

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

- Complete this application form.

For more information, please contact MedWish International at domesticaid@medwish.org or call 216.692.1685 x66.
PARTNER AGENCY FORM

Must be completed annually

Please be sure to review the application instructions before proceeding.

Once MedWish receives the application, we will follow up with you to discuss next steps or to request additional information.
Official name of organization/program: *
Type a question *

School Social Agency Faith-base group
Primary Administrative Contact *

First Name Last Name
Title *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Website
Insert website here
Phone Number *

Area Code Phone Number
Facebook address
example@example.com
Primary on-site contact (if different from above)

First Name Last Name
Title

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email
example@example.com
Phone Number

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

I've volunteered at MedWish before Internet search I was referred by someone
If you were referred to MedWish 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: *
Approximate number of staff: *
Approximate number of consumers served annually: *
Approximate number of consumers that will benefit from this request: *
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? *
LOGISTICS AND PROCESSING/HANDLING FEE - Does the organization have the ability to pick up the donations? *

YES NO
IMPORTANT:

- Items will only be provided to partner agency representatives.
- Items will not be directly handed to any recipients; therefore, recipients should not try to pick up items from MedWish, or coordinate direct drop offs.
- If delivery is requested by the partner agency, please know that each drop off is subject to a $35 drop off fee (25 miles ratio).
- MedWish team will be responsible for unloading the item(s) from the truck. Partner agency representatives will be responsible for all transfer and movement of the item(s) once unloaded.
Who will be responsible for paying the processing/handling fee? *

Organization/agency contact listed on this form Sponsor organization – If so, please notify the MedWish Rep.
Anticipated Payment Method *
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 - $10ea IV Pole - $10ea Nebulizer machine - $20ea Over-the-bed tray tables - $20ea Shower chairs - $10ea Walkers (collapsible) - $10ea Rollators - $25ea Manual wheelchairs - $40ea Bariatric Bed - $225ea Home health bed - $150ea Wheeled lab stool - $10ea Hoyer Lift - $40ea Disposable 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. 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 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 representative. MedWish 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 Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
CONSENT AND LIABILITY RELEASE

Legal Statement

The medical supplies, equipment and materials available from MedWish International are items that would otherwise be discarded from healthcare facilities and/or providers in the United States. 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, and 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 International, 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.
Applicant's full name *

First Name Last Name
Organization/Agency name: *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email *
example@example.com
Phone Number *

Area Code Phone Number
Date *

Month Day Year
Date Date Picker Icon
Signature

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