Assistive Technology Equipment Request Form

Assistive Technology Equipment Request Form
Student Name*

First NameLast Name
Student ID#*
Date of Birth*

MonthDayYear
Date
Requested for Trial/checkout*

MonthDayYear
Date
DURATION: Note: To determine appropriateness equipment a trail period or some form of assessment is mandatory prior to purchase.
CAMPUS CONTACT INFORMATION OF PERSON CHECKING OUT EQUIPMENT:
Name*

First NameLast Name
Job Title:*
Campus phone#*

Area CodePhone Number
Date submitted to the assistive technoldy department:*

MonthDayYear
Date
I UNDERSTAND THAT THIS EQUIPMENT IS CHECKED OUT UNDER MY NAME AND I ASSUME ALL RESPONSIBILITY FOR THE LOCATION OF THE DEVICE:
Type a question*

YESNO
Signature*
Should be Empty: