Chippewa Hills School District Assistive Technology Request
Please fill in as much information as possible so a member of the MOISD Assistive Technology team can reach out to you to support assistive technology needs for a student. Once you have submitted this form, a MOISD Assistive Technology Team Member will reach out to you in 5 school days to address the request.
Email address *
Referring Person's First and Last Name *
Your answer
Referring Person's Job Title *
Your answer
Contact Phone Number
Your answer
Best Time to Contact Referring Person
Your answer
Student's First and Last Name *
Your answer
Building
Student's Grade
Please check from the following options.
What challenges or difficulties is the student having? *
Your answer
What activities does the student need assistance with performing?
Your answer
What assistance has been tried and what were the results?
Your answer
A copy of your responses will be emailed to the address you provided.
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