Adaptive Toy Request Form

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Please fill out this form to request free adapted toys. We will do our best to fill the requests depending on available funding. To learn more about our Adaptive Toy Program, please visit www.wallawalla.edu/academics/areas-of-study/education-and-psychology/ceed/adaptive-toy-program/.

Email *

First and last name of the individual completing this form: *

Phone number of the individual completing this form:

Best method of contact:

Phone

Text

Other:

Clear selection

I am requesting an adapted toy on behalf of a: *

School

Clinic

Non-profit

Individual family or child

Other:

Name of the organization:

Contact information for the organization (address, phone, email, website):

Name of the family or child receiving the toy:

What is the child's age?

What school does the child attend?

Please write a description of the child's disability to the best of your ability.

Adapted Toy Information

Please answer the following questions and we will do our best to fill your adapted toy request.

How many toys are you requesting for this organization or family/child? *

Do you have a preference for which adapted toys you receive? (Find available toys at https://docs.google.com/presentation/d/1LOOnce3Jdg6vfeW6eIqFsIfEKQhVSnfy8GFpz6czv0w/edit?usp=sharing) Please indicate a quantity for each toy.

If you would like to provide a specific toy or request a custom toy not listed on our website, please give us a description and/or website for the toy. (We cannot guarantee all custom toy request to be adaptable, but will take all requests into consideration.)

Do you have access to a switch or switches to activated the adapted toy? (see examples at www.enablemart.com/switches)

Yes

Clear selection

If answered no, do you need financial assistance in purchasing a switch? (We will prioritize those with the greatest needs due to limited funds)

Yes

Other:

Clear selection

What kind of switch or switches would best suit your organization or family/child's needs?

Any other comments or suggestions:

Submit

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