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Supply Request Form   arrow

To receive your free supplies, please complete the following Supply Request Form and submit after reading and agreeing to the disclaimer at the end of the form.  We are very grateful to receive many supply donations from other T1D’s.  We will do our best to provide you with what you need, however we do not have a complete inventory of all manufacturers and diabetic supply types.  If we have what you need we will ship it out right away.  If not, we will keep your request on file and ship if we receive what you need.

While we do not charge for any of these supplies, we do request a donation to cover shipping and handling.  $15 is the suggested donation.  If you can afford a bit more for more expensive supplies, that will be very appreciated.

Click here to find additional information on other sources for supplies provided by our friends at CarbDM.

Your Name (required)

Your Email (required)

Your Phone Number (required)

Relationship to Type 1 Diabetic
Select all that apply:

If other, please specify:

Age of Type 1 Diabetic
0-1011-1819-24

Shipping Address
Street Address

Apt/Suite Number

City

State

Zip Code

Supply Needs (Please indicate items including manufacturer/brand)

Will you accept expired supplies?
yesno

Indicate the latest expiration date you will accept
1 month2 months3 months4 months5 months6 months

Tell us about you. Please write a few sentences about yourself and how these supplies will improve your diabetes management

May we share your comments?

DISCLAIMER OF WARRANTIES
AND
ACKNOWLEDGEMENT, WAIVER AND RELEASE FROM LIABILITY

AMERICAN BOARD FOR CHILD DIABETICS (“ABCD”) IS A CALIFORNIA NONPROFIT PUBLIC BENEFIT CORPORATION AND, THROUGH THIS WEBSITE OR OTHERWISE, DOES NOT OFFER OR PROVIDE MEDICAL CONSULTATION, DIAGNOSIS, ADVISE OR TREATMENT.  ALL INFORMATION ON THIS WEBSITE (OR OTHERWISE PROVIDED BY ABCD) IS FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED TO SERVE AS A SUBSTITUTE FOR THE CONSULTATION, DIAGNOSIS, ADVISE OR TREATMENT OF A LICENSED AND QUALIFIED PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL.

THE SUPPLIES AVAILABLE ON THIS WEBSITE ARE BEING PROVIDED AS IS, WITH ALL FAULTS, AND WITHOUT WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING ANY WARRANTY THAT THE SUPPLIES ARE MERCHANTABLE OR FIT FOR A PARTICULAR PURPOSE.  THE RECIPIENT OF THE SUPPLIES ACKNOWLEDGES AND UNDERSTANDS THAT THE SUPPLIES HAVE BEEN DONATED TO ABCD, THAT ABCD IS NOT RESPONSIBLE FOR THE MANUFACTURE, DISTRIBUTION, SALE OR MAINTENANCE OF THE SUPPLIES, AND THAT ABCD DOES NOT OFFER OR PROVIDE (THROUGH THIS WEBSITE OR OTHERWISE) ANY MEDICAL CONSULTATION, DIAGNOSIS, ADVISE OR TREATMENT.  THE ENTIRE RISK AS TO THE APPROPRIATNESS, SUITABILITY, QUALITY, PERFORMANCE AND USE OF THE SUPPLIES IS WITH THE RECIPIENT.

THE RECIPIENT OF THE SUPPLIES AGREES TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH SHOULD THE SUPPLIES BE MISUSED OR PROVE DEFECTIVE IN ANY WAY.  THE RECIPIENT HEREBY RELEASES ABCD FROM ALL LIABILITY, ACTIONS, CLAIMS OR DEMANDS FOR INJURY, DAMAGES OR LOSSES THAT IN ANY WAY RESULT FROM THE USE OR DEFECTS OF THE SUPPLIES.

BY AGREEING, THE RECIPIENT OF THE SUPPLIES ACKNOWLEDGES THAT HE OR SHE HAS CAREFULLY READ THE FOREGOING PROVISIONS, INCLUDING THE DISCLAIMER OF WARRANTIES AND WAIVER AND RELEASE OF LIABILITY, FULLY UNDERSTANDS THE CONTENTS THEREOF, AND IS AWARE THAT THIS IS A FULL RELEASE OF LIABILITY.

I accept: