Back in Use Equipment Request Form


Fill out this section if you are submitting this form on behalf of somebody else


Recipient section



* These fields are required.

*Power scooters and wheelchairs require Proof of Disability (POD) from your physician. Your equipment request cannot be processed until your POD is received.

[/et_pb_cta][et_pb_text _builder_version="4.25.1" custom_margin="-45px|||62px" custom_padding="0px|||" hover_enabled="0" global_colors_info="{}" sticky_enabled="0"]

Proof of Disability(POD) can either be mailed to: Back In Use, 1520 First Street NW, Albuquerque NM 87102, or emailed to: backInUse@goAdelante.org.

[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built="1" fullwidth="on" _builder_version="4.16" global_colors_info="{}"][et_pb_fullwidth_code _builder_version="4.16" background_color="#e02b20" hover_enabled="0" global_colors_info="{}" sticky_enabled="0"]
[/et_pb_fullwidth_code][/et_pb_section][et_pb_section fb_built="1" fullwidth="on" _builder_version="4.16" custom_margin="0px||0px|" custom_padding="0px||0||false|false" global_colors_info="{}"][et_pb_fullwidth_header title="Help Adelante's Back in Use Program" text_orientation="center" button_one_text="Get Involved" button_one_url="/get-involved/" _builder_version="4.16" custom_margin="0px||0px|" custom_padding="0px||0px|" hover_enabled="0" global_colors_info="{}" button_one_text_size__hover_enabled="off" button_two_text_size__hover_enabled="off" button_one_text_color__hover_enabled="off" button_two_text_color__hover_enabled="off" button_one_border_width__hover_enabled="off" button_two_border_width__hover_enabled="off" button_one_border_color__hover_enabled="off" button_two_border_color__hover_enabled="off" button_one_border_radius__hover_enabled="off" button_two_border_radius__hover_enabled="off" button_one_letter_spacing__hover_enabled="off" button_two_letter_spacing__hover_enabled="off" button_one_bg_color__hover_enabled="off" button_two_bg_color__hover_enabled="off" sticky_enabled="0"][/et_pb_fullwidth_header][/et_pb_section][et_pb_section fb_built="1" _builder_version="4.16" background_color="#E02B20" global_colors_info="{}"][et_pb_row _builder_version="4.16" background_color="#ffffff" border_width_all="40px" border_color_all="#ffffff" global_colors_info="{}"][et_pb_column type="4_4" _builder_version="4.16" custom_padding="|||" global_colors_info="{}" custom_padding__hover="|||"][et_pb_text _builder_version="4.25.1" global_colors_info="{}"]

Thanks to our supporters!

[/et_pb_text][et_pb_code _builder_version="4.16" hover_enabled="0" global_colors_info="{}" sticky_enabled="0"][wpaft_logo_slider category="biu"][/et_pb_code][/et_pb_column][/et_pb_row][/et_pb_section]