Grade 5 and 6 iPad Loan Agreement Signature Page 2022-23

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Please complete this form for EACH 5th or 6th grade student you wish to take an iPad home. For example, if you have two children, you'll need to complete the form twice - one for each.

You may have completed this permission form in the Annual Back to School Update. If you did, there is no need to complete this form again.

Parent Guardian Information

Please complete the following section with information about you, the parent or guardian

Parent / Guardian Name (FIRST and LAST) *

Parent / Guardian phone number *

Parent / Guardian email address *

Student Information

Please complete the following section with information about the student taking the iPad home.

Please select the school your student attends: *

Who is your student's classroom teacher? *

What grade is your student in? *

Please indicate if you are needing an iPad charger to be sent home with your student. (NOTE: If you receive a charger/charge cable, you understand that you will be responsible for returning it or paying for a replacement) *

Yes, I need an iPad AND a charger/charge cable

No, I do NOT need a charger/charge cable

Student's LAST name *

Student's FIRST name *

Cooperative Loss and Digital Signature

Repairing damaged or replacing lost/stolen District-owned technology can be costly. The costs to you in situations like this can be significantly reduced by participation in our optional Cooperative Loss Program. A copy of the Technology Damage/Loss Cooperative Fund Description of Terms has been made available to me, and by my selection below, I indicate that I understand and agree to the terms contained therein. Either Yes or No must be selected. The price for the current school year is $25.00 standard, with a reduced rate ($12.50) for families who have a free or reduced lunch status. *

Yes - Bill Me, I want to participate in the optional Damage/Loss Cooperative. I understand I will recieve an invoice and the fee must be paid before coverage begins.

No- I decline to participate at this time, and I understand that I am responsible for 100% of any damage or loss to the loaned iPad.

I have been provided a copy of the iPad Loan Agreement Description of Terms and iPad Introduction/Principles/Guidelines and by my signature below, indicate that I understand and agree to the terms contained therein. I understand that any use deemed irresponsible, inappropriate, or in violation of the student code of conduct by the District may result in the loss of his/her right to possess and/or use this iPad and may also result in disciplinary or other action.

Parent/Guardian Digital Signature (Please type your name below.) *

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