Nomination/Application Forms

Nomination Form

We are looking for our next recipient.  If you know someone that is need of a device to get back to or begin an active lifestyle, please click on the link above to fill out the nomination form.

Application Form

We are looking for our next recipient.  If you would like to be our next recipient of a device to get you active, please click on the link above to fill out the application form.

Request form 

Amputee Wellness Alliance of the Midlands (AWA) is a non-profit organization who raises funds to help beneficiary(ies) get smaller items needed throughout the year, until the funds run out.  Funds will be paid out directly to the clinician who is providing the device/supplies to help the recipient(s) get back to their active lifestyle.  Please click on the link above to fill out request form.

You may contact us at awamidlands@gmail.com