Supply Donation Form "*" indicates required fields Thank you for considering a donation of diabetes supplies. Every contribution helps us continue our mission of supporting those affected by diabetes with the resources they need. We deeply appreciate your generosity and commitment to making a positive impact in the lives of others.We are collecting unopened and untampered with test strips, KetoStix, glucose meters, lancing devices as well as other diabetes supplies, for redistribution to individuals living with diabetes. All items are provided, free of charge, to individuals with diabetes who otherwise would go without these life saving devices. List of supplies we accept: KetoStix: Boxed must be new and unopened with a minimum of three months to use-by date. New, unopened boxes of any brands are accepted. Glucose Meters: Meters must be in excellent working condition and have not been discontinued. The manufacturer of meters must be currently making test strips for that model to be accepted. Lancing Devices: Unopened, new lancing devices from any brand are accepted. Glucagon: All glucagon must have a minimum of three (3) months to use-by date. Lilly Glucagon, GlucaGen, Basquimi are all accepted. Insulin Pump Supplies: We are unable to accept donations of insulin pumps. We can accept infusion sets for pumps. Glucose Test Strips: Unused, sealed glucose test strips must have a minimum of ninety (90) days to use-by date. All brands of sealed test strips are accepted. Lancets: All lancets must have a tamper proof factory seal with a minimum of seven (7) months to use-by date. We are only permitted to work with factory sealed lancets. Any type of brand of lancet are accepted. If no date is printed, the sterility of lancets lasts 5 years from the date of manufacturing. Continuous Glucose Monitor (CGM) Supplies: We accept Dexcom FreeStyle Libre, and Medtronic Guardian sensors with at least ninety (90) days, All CGM readers are accepted and must be new. Dexcom transmitters must have at least four (4) months until expiration date. *If the item you are donating does not have an expiration date, we can accept it up to 5 years from the manufacturing date. We do not accept insulin pumps. For any questions, please don’t hesitate to call us at 201-444-0337.DONOR INFORMATIONName* First Last Organization (if applicable) Organization Name Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number*Email Address* If you do not have an email address, please put N/A Reason for donationHow did you hear about our program?* Healthcare Professional (Hospital Personnel, Doctor or Pharmacist) Google Search Social Media (Facebook/Twitter/Instagram/Linked-In) Non-Profit or Government Agency School Other Donor Certification of In-Kind ContributionAll donations should be mailed to 45 Whitney Rd 2M, Mahwah NJ 07430. Please call 201-444-0337 with any questions. I, the undersigned, hereby certify that the item(s) I am donating to the Diabetes Foundation are: Unused, Unopened, & Unexpired (if applicable)* Yes No Please list all supplies you will be donating:Please list the quantity of what you will be donating:Please list the expiration date(s)I affirm that the above information is true and accurate to the best of my knowledge.* Yes No Signature:* Signature of Donor Date MM slash DD slash YYYY
