Equipment/Toy Request Application
Please fill out this top form and select up to 3 options. Whether we can accommodate all 3 options will be determined by number of applications and available funds. We have pre-selected some options but if your child wants or needs a specific item that you do not see on this list, please enter it under the last box on the form marked 'Other'. If you are having difficulty with this form please email us directly at LiveLikeLilBill@gmail.com.
Your Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Doctor/Therapist Referral
*
Doctor/Therapist Referral Number
*
Please enter a valid phone number.
Primary Diagnosis
*
How did you hear about us?
*
Equipment/Switches
*
Categories:
All
All
Equipment/Switches
Switch Adapted Toys
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Equipment/Switches
Hitch 2 (Switch Interference)
$
99.00
Wobble Switch
$
100.00
Specs Switch
$
65.00
Power Link 4
$
255.00
Little Step-by-Step with Levels
$
195.00
BIGmack
$
135.00
Jelly Bean Switch
$
65.00
Big Red Switch
$
65.00
Dual Switch Latch and Timer
$
135.00
Battery Interrupter (AA or C/D)
$
17.95
Activity Gym
$
259.95
Switch Adapted Toys
Switch Adapted Walking T-Rex
$
40.00
Switch Adapted Flappy the Elephant
$
75.00
Switch Adapted Pretty Poodle
$
55.00
Switch Adapted Bump-N-Go Bubble Train
$
40.00
Switch Adapted Bubble Machine
$
75.00
Switch Adapted Peek-A-Boo Bear
$
95.00
Switch Adapted Penguin Race
$
55.00
Adapted Color Spinout (switch adapted)
$
139.95
Aqua Dome
$
189.95
Baby Pug
$
43.95
Bingo
$
159.95
Bubble Blastin' Machine
$
43.95
Adapted Pie Face
$
135.95
Clubhouse Fun Mickey
$
85.95
CD Boom Box
$
139.95
Drum
$
117.95
Drumbourine
$
137.95
Please provide a link or a detailed description to any other options you may want/need.
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