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
Signature
Should be Empty: