P.S. 211 Elm Tree Elementary Student Device Request & Student Device Loan/Return Agreement Form
Please be advised that filling out this form is required before our school's Tech Team is allowed to assign a personal device to your child. 

Once filled out your child will be receiving a personal device for instructional use. 

The device will provide access to Google Apps for Education, Clever, iReady, and other web based
tools to foster student creation, collaboration and creativity.
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Email *
Responsibilities:
1. It is the responsibility of the student and parents/guardians to exercise reasonable care of the
device at all times. Please do not break the case, the screen or the provided wires. 

PLEASE NOTE THAT: If the device is returned to our Tech Team and it is damaged or broken then the parent/guardian of the student may be responsible for paying for the repairs/replacement of the device.

2. Students are expected to bring the device with them to school every day, ready to use, fully
charged, and in the provided case.

3. Please do not create a passcode to lock the device as this device is not for personal use. There
should be no personal or confidential data stored on the device as the device is monitored by the NYCDOE.

4. If you leave the school, you must return the device.

Please select "Agree" below to confirm that you have read the "Responsibilities" section above and agree with all four (4) of the statements listed: *
Please Read & Print Your Name Below:
We have read, understand, and will comply with all policies and procedures within this
document. 

I will be responsible for monitoring my child at all times while the iPad® is at home or
in my presence.

As the parent, I agree to immediately return the iPad and wires in good working condition upon
withdrawal from PS 211. 

I acknowledge that this handbook and policy is to be used as a guide
and does not attempt to address every required or prohibited behavior by its users.
Please select whether you are REQUESTING a device or RETURNING a device: *
Parent Full Name: *
Parent Phone Number: *
Parent Email: *
Date of Request: *
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Student ID/OSIS #: *
Please check with your child's teacher, call our main office or contact our school's parent coordinator if you need assistance with retrieving your child's ID/OSIS #.
Student First Name: *
Student Last Name: *
ATS Class: *
Please provide the reason that your child needs an assigned device *
Required
A copy of your responses will be emailed to the address you provided.
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