Donation Request Form


Donation Request Form

​​​​​​​Please submit your request at least 6 weeks before needed.

We receive many inquiries and will do our best to accommodate as many as possible, but please note we may not be able to fulfill all donation requests.​​​​​​​

Organization Name*
Contact First and Last Name*
Contact/Organization Email*
Organization Website
Contact Phone Number*
Address*
City, State, Zip*
Which Active Family Chiropractic & Acupuncture location are you requesting funds from?
Request*
If other, please explain below:
Will Active Family Chiropractic & Acupuncture receive any recognition for our donation? If so, what would that be?*
Is the contact a current patient of our office? If yes, who is your doctor?*
Materials Needed By*
Is there anything else you would like us to know?
Please submit any files with additional information below.
Roya1234 Holistic Treatments Health and Wellness Coaching How Chiropractic Can Help With Weight Loss Cranial Facial Release Physiotherapy Treatments Therapeutic Adjustments Massage Therapy Trigger Point Injections 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 7:30 am - 6:00 pm 8:00 am - 6:00 pm Closed Closed chiropractor https://www.google.com/search?rlz=1C1JPGB_enUS814US814&ei=pUIJXbvMEODB0PEPiuqTiA8&q=active+family+gi&oq=active+family+gi&gs_l=psy-ab.3..0i22i30l10.31447.31503..31737...0.0..0.74.147.2......0....1..gws-wiz.......0.x2MB5ODwxO0#lrd=0x879986c3a3cd15af:0x7522e7b440ff2d25,3,,, https://www.yelp.com/writeareview/biz/fOBijqTvTDYrSVjKg2iD-A?return_url=%2Fbiz%2FfOBijqTvTDYrSVjKg2iD-A&source=biz_details_war_button https://www.facebook.com/activefamilygi/reviews/?ref=page_internal https://www.google.com/maps/place/Active+Family+Chiropractic+%26+Acupuncture/@40.9245111,-98.378611,19.25z/data=!4m5!3m4!1s0x0:0x7522e7b440ff2d25!8m2!3d40.924615!4d-98.3782349 https://www.facebook.com/activefamilyhastings/ https://goo.gl/maps/p5voSzocGzNPwZAc7 https://www.youtube.com/channel/UCDhFRb9p2Y53xsS4T9I793g https://www.yelp.com/biz/active-family-chiropratic-and-acupuncture-hastings activefamilyhastings@gmail.com 4022495500 3602 Cimarron Plaza #340
Hastings, NE 68901 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm Closed Closed https://www.google.com/maps/place/Active+Family+Chiropratic+%26+Acupuncture/@40.6213083,-98.3853218,19.5z/data=!4m5!3m4!1s0x0:0x1a2533ac93237ab7!8m2!3d40.6213856!4d-98.3848041 2441 North Diers Ave.
Grand Island, NE 68803 3083844955 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 7:30 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 11:00 am Closed https://www.google.com/maps/place/2441+Diers+Ave,+Grand+Island,+NE+68803,+USA/@40.9449425,-98.3849747,20z/data=!4m5!3m4!1s0x87998725466f956d:0x5d4570c9b2543778!8m2!3d40.945031!4d-98.38459