2020-2021 Madison High School Device Request Form
Please complete the following form if you are in need of a school issued device for virtual learning. Please complete one form per student enrolled at Madison High School for which a device is requested.

By submitting a request you are agreeing to the following terms of use:

-Take responsibility for technology provided and use the equipment for educational purposes only.

-Maintain the equipment in working condition while said equipment is in your possession.

-Return the equipment in the same working condition that you received it to designated personnel.

-Agree to and understand that if the technology equipment, software, and other related items are stolen, vandalized, misplaced, destroyed, etc. that you are responsible and will reimburse (pay) the District the amount required to replace or repair the equipment.

There is no charge to borrow a school device, but there could be fees charged for damaged or lost items as follows:

Responsible party will be required to pay:
$25 replacement fee for lost/not returned or damaged power adapter
$50 repair fee for missing keys
$100 repair fee for cracked/broken screen/keyboard
Up to $250 replacement fee for destroyed, lost, or not returned device

Email address *
Device deployment is scheduled to take place during Eagle Days, August 31 (9th and 10th Grade) and September 1 (11th and 12th Grade). More information will be shared during the Virtual Orientation sessions (August 27).
Please complete one form for each child for which you wish to request a device.
Student Last Name *
Student First Name *
Student Grade *
Parent/Guardian Last Name *
Parent/Guardian First Name *
Do you have reliable internet access to connect the device(s)? *
Parent Phone number: *
Full Address *
Equipment provided will be used for educational purposes only. *
Equipment must be maintained in working condition while said equipment is in your possession. *
Return the equipment in the same working condition that it was received it to the designated personnel. *
Agree to and understand that if the technology equipment, software, and other related items are stolen, vandalized, misplaced, destroyed, etc. that I am responsible and will reimburse (pay) the District the amount required to replace or repair the equipment. *
By requesting a device, I acknowledge and understand that I am responsible for:
Up to $25 replacement fee will be charged for a lost/not returned or damaged power adapter *
$50 repair fee for missing keys *
$100 repair fee for cracked/broken screen/keyboard *
Up to $250 replacement fee will be charged for a destroyed, lost, or not returned iPad *
A copy of your responses will be emailed to the address you provided.
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