Makers Making Change's Hacking for the Holidays Request Form:

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Please fill out the form below to indicate your top three choices of toy and your contact information. We are asking for the referral person, clinic or where you received the Wish Book from, in hopes that we can coordinate pick up locations that are convenient for all. We will indicate where toys can be picked up, or can work out alternate arrangements once this form has been filled out. There is also an option at the bottom of this form should you wish to share anything further.

Email *

Name: *

Contact Info: (Phone number or email) *

Area and Province: *

Wish Book/ Referral was sent by:

(Clinician name or agency)

Please choose your first choice of toys from the Wish Book: *

Please choose your second choice of toys from the Wish Book: *

Please choose your third choice of toys from the Wish Book: *

If you would also like a switch accompanied with your toy, please indicate which switch type you would prefer.

Please note: if you are unsure of which preferred type, we will be working with clinicians to have various types to trial.

MMC 60 Switch

Open AT Latch Switch

Interact Switch

Light Touch Switch

Low Profile Switch

Please indicate if there is anything further you would like us to know:

Submit

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