Wheelchair Loaner Request

"*" indicates required fields

1Applicant Information

2Confirmation

Full Name*

Email*

Teléfono*

Habla a*

Are you a Veteran?*

Date of birth*

Date of your injury*

Tipo de discapacidad*

Level of injury*

Causa de la lesión*

How did you hear about the Triumph Foundation Wheelchair Loaner Program?*

Please write a bio that describes how you were injured, the degree of your disability and how it affects your everyday life.*

Wheelchair Information

Years in a wheelchair*

Type of wheelchair requesting*

Have you requested a wheelchair from your insurance?*

If YES, from what company?*

Seat pan width*

Seat pan length/depth*

Do you have a cushion?*

Additional comments

Other Equipment Requests

Other equipment request?

Special features/needs?

Upload Supporting Documentation

iOS (Apple mobile device) Users!

BEFORE taking pictures and uploading to this form, make sure your camera capture setting is set to "Most Compatible." See instructions in the "Capturing this media" section AQUÍ

NOTE: If this setting is updated on your device, you must retake the photos before uploading them to this form.

Please upload TWO picture of you in your current wheelchair. One facing forward and one side profile.*

Drop files here or

Accepted file types: doc, pdf, jpg, jpeg, png, Max. file size: 64 MB.