Assistive Technology Equipment Request Form
Please submit this form when requesting to use equipment from the Eisenhower Cooperative. Once the request has been made, the AT department will review and contact the person submitting if any additional information is needed.
Person Responsible for the Equipment *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
School *
Your answer
District/Program *
Item Requested *
Please use a separate request form for each piece of equipment needed (example: one form for iPad and one form for case). Please indicated if the technology requires a specific program, app or software installed on it.
Your answer
Purpose of Request *
Your answer
Is this equipment being used for a specific student? *
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