Goodwill HELPs Application

Use the form below to apply for assistance from the Goodwill HELPs program

HELPs Application Form

Safety & Independence for residents of Southeast TN and Northwest GA HELPs is a program service of Chattanooga Goodwill Industries, Inc. ALL FIELDS MUST BE FILLED OUT COMPLETELY. ALL INFORMATION PROVIDED WILL BE TREATED AS CONFIDENTAIL
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • If requesting a wheelchair or C-Pap, a prescription is required. Please upload a copy of your prescription to this application.
  • *Information is for tracking purposes only. We will not bill your medical insurance for items or services received.
  • Person to contact other than above

  • WAIVER

    I/we understand that Goodwill HELPS is a medical equipment lending program designed to serve our community without charge for services or equipment, and therefore agree to accept the equipment in “as is” condition. I/we also commit to return the equipment in good condition at such time as I no longer have a need for it. I/we have consulted with our personal team of medical professionals and assume all responsibility for the selection of equipment to meet the needs of myself or the person who will be using the equipment. I hereby, for myself and the person using this equipment, our heirs, executors and administrators, waive and release any and all rights and claims for damages we may have against Goodwill HELPS, Chattanooga Goodwill Industries, Inc. or any other persons connected with this program, their agents, representatives and assigns for any and all injuries suffered by, or illness to ourselves resulting from the use of said equipment.
  • Date Format: MM slash DD slash YYYY

Print an application

Fax completed applications to
(423) 242-0504.

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