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
Atwood Heights School District 125
Alsip Hazelgreen Oak Lawn School District 126
Worth School District 127
Chicago Ridge School District 127.5
Cook County School District 130
Calumet Park School District 132
Posen-Robbins School Distrct 143.5
Community High School District 218
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.
Purpose of Request
Is this equipment being used for a specific student?
No (classroom use)
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This form was created inside of Eisenhower Cooperative.