• 605-430-9361

MOON’S BRIDGE EQUIPMENT REQUEST FORM – Revised June 2020

Moon’s Bridge, Inc. will award equipment requests throughout the year to a child with a confirmed medical need for the requested equipment.

This will be determined upon Moon’s Bridge Board Approval.

all fields marked with an asterisk (*) are required

ATTACH AT LEAST ONE OF THE FOLLOWING:
A. Medical Prescription from the primary care physician
B. Current History & Physical within the past 6 months
C. Current OT Evaluation stating the recommendation for the specific equipment being requested

STATEMENT OF ACCURACY FOR APPLICANT
I hereby affirm that all the above stated information provide by me is true and correct to the best
of my knowledge. I also consent that if chosen as a recipient of equipment my picture may be
taken and used to promote Moon’s Bridge, Inc. equipment donation program.
I hereby understand I will not submit this application without all required attachments and
supporting documentation. Incomplete applications or applications that do not meet the criteria
with not be considered for this scholarship.

CHECKLIST___APPLICATION ___ (1 FORM) FROM QUESTION # 6 ___ PARENT CONTACT
INFORMATION IS CURRENT

MAIL COMPLETE APPLICATION PACKAGE TO MOON’S BRIDGE, INC
C/O MONIKA SHUMBO-POISSANT, OTD, OTR/L, ATRIC
3958 SOUTH DEVANE DRIVE – YUMA, AZ – 85365
Cell Phone – 605-430-9361 / Email – Moon@moonsbridge.com
The deadline for this application to be received by Moon’s Bridge, Inc. office is:

February 1st/ April 1st/ June 1st/ August 1st or October 1st