Ben's Toy Closet Application

This is the application for toys and devices. To request a toy, switch or other device, please complete the below application fields. Once completed, you will be contacted within five business days with status or next steps. We cannot guarantee to provide everything that is requested but will do our very best to bring a smile to your child's face.

Child Name

First Name

Last Name

Mother Name

Father Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Email Address

Child Birth Date

Child's Diagnosis

Please provide brief background/history of your child.

Referring Therapist

Therapist Phone/Email

Describe Focus/Progress in Therapy

Items Requested

Please identify which items you are requesting for your child/client:

Activation Switch

Adapted Switch Toy

Big Mack Recordable Device

Other

Financial Need

Is there family financial need?

Any More information for us to consider?

Photo Release

I agree to provide photographs of my child with the toy gift that can be used solely and specifically on Bensmiles.org or on Ben's social media accounts.

I agree

I do not agree