Request Equipment

Join Our Lending Program

If you are interested in borrowing specific medical equipment from our equipment locker,
please submit this form and we will be in touch soon. Thank You!

Equipment Request Form

* Indicates required field

Equipment Pickup or Delivery (a date/time will need to be coordinated for both options) *

I will pick up the Equipment at Game Plan 4 Hope: 312 W. 3rd St. Hills, MN 56138 -OR- a meet up location can be coordinated I request delivery to the below address

Name *

First

Last

Equipment Delivery Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Equipment being Requested *

Please Describe Situation or Reason for Requesting Equipment *

I agree to receiving marketing and promotional materials

Submit

Equipment Locker

Join Our Lending Program

Equipment Request Form

GAME PLAN 4 HOPE

CONNECT

Equipment Locker

Join Our Lending Program

Equipment Request Form

​GAME PLAN 4 HOPE

CONNECT

GAME PLAN 4 HOPE