AT Equipment Request Form

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Email *

Request Made By *

Name of individual completing this form

Name of School Contact (If not the same as the individual completing form.) *

Individual responsible for device during trial period and equipment return (teacher/therapist)

School Contact Email *

Campus *

Student's Name *

Student's Grade Level/Age

Please list the equipment you wish to borrow. Be as specific as possible. Equipment that is to be used together should be placed on one form. When several different pieces are desired, separate forms are needed. (ex: If you need an AlphaSmart, mounting system and switch – these would go on one form. AlphaSmart and FM System would go on separate forms). *

Date Equipment is Needed *

Note, this does not guarantee equipment will be available at this date.

YYYY

Date Equipment will be Returned *

End of trial period, or school year end date

YYYY

Any other questions or comments

Submission of this Equipment Request Form indicates your agreement to the following: *

The school agrees to return the equipment at the end of the loan period.

The school agrees to reimburse the special education department for the cost of the equipment listed above should it be lost, stolen, or damaged during the time that the equipment is in the school.

Required

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