Adobe FormsCentral

First Name *

Last Name *

Type of Organization

Region

Name of Organization or School

Street Address *

City *

Province

Postal Code *

Telephone Number *

Email: *

Type of Equipment *

Quantity *

Size (if required)

Type of Equipment

Quantity

Size (if required)

Type of Equipment

Quantity

Size (if required)

Type of Equipment

Quantity

Size (if required)

Type of Equipment

Quantity

Size (if required)

Type of Equipment

Quantity

Size (if required)

Type of Equipment

Quantity

Size (if required)

Preferred pick up date *

Day Month Year

Preferred return date *

Day Month Year

Estimated number of users with a physical disability: *

Estimated number of users without a physical disability: *

How often do you intend to use the equipment?

How did you hear about the Equipment Loan Service?

Do you have a locked method of storage for the duration of your loan?

Yes No

Donations to the Equipment Loan Service are appreciated! A charitable receipt will be provided upon request. Please make cheques out to Ability NB. Enter intended donation amount below and thank you for your contribution!

Would you like to receive our e-newsletter? *

Yes, please No. thank you

Would you like to be registered in the Para NB database so you may be contacted regarding sports and recreation opportunities in your region as they develop?

Yes, please No, thank you

Terms and Conditions

Requests will be processed in the order they are received and equipment will be allocated according to date received and need, as prioritized by the Equipment Loan Service Coordinator.
Requests must be received at least 30 days prior to requested loan date.
Where requested equipment is unavailable, the applicant will be notified and placed on a waiting list.
Successful applicants will be required to sign an Equipment Loan Agreement which will be provided by Para NB upon pick up.
Loans are to be a maximum of 30 days. Loans will only be renewed if the requested equipment is available and at the discretion of the Equipment Loan Service Coordinator.
Equipment can be picked up and dropped off in Fredericton by appointment. Office hours are Monday to Friday, 8:30am-4:30pm.
It is the loanee's responsibility to arrange transportation of equipment. If transportation cannot be acquired, contact the Equipment Loan Service Coordinator to make alternate arrangements.

I agree to these terms and conditions. *

Yes, I agree

Date request is submitted: *

Day Month Year

If you have any questions or concerns, please contact us at:

Para NB-Sport & Recreation

c/o Ability New Brunswick Inc.

440 rue Wilsey Road, Suite 102

Fredericton, NB E3B 7G5

Tel: 506.462.9555/1.866.462.9555 Fax: 506.458.9134

info@paranb.ca/www.paranb.ca

Equipment Loan Service Request Form