Illinois Assistive Technology Program

Device Loan Request Form

  1. COMPLETE THE FOLLOWING FOR THE PERSON REQUESTING THE EQUIPMENT
    Name
    Phone Number Alt. Phone Number
    TWO PHONE NUMBERS MUST BE PROVIDED

    Place of Employment

    Home Address
    City State ZipCode County
    Fax Number E-Mail

    Type of Individual or Entity requesting equipment. (please select the option which best describes the capacity in which you are requesting equipment)


    The primary purpose for which I need (or the person I represent needs) an AT device or service is related to:
    - Participating in any type of educational program
    - carrying out daily activities, participating in community activities, using community services, or living independently.
    - Finding or keeping a job, getting a better job, or participating in an employment training program, vocational rehabilitation program, or other program related to employment.
    - Using computers, software, web sites, telephones, office equipment, and media.

    Please indicate if you receive or have received services from any divisions of the Illinois Department of Human Services.


  2. Complete this section for the person who will be USING the equipment
    Age Range Race / Ethnicity

    Disability

  3. Equipment requested
    Name of Item
    Name of Item
    Name of Item
    Name of Item

  4. Primary Purpose


    Do you borrow assistive technology equipment from another source?


  5. Address for delivery where someone is available Monday thru Friday, 9am to 5pm. Do not use a P.O. Box number for shipping address, you must incluse a street reference. If delivery is at a large facility you must specify department and/or room number.


  6. Please read and sigh BOTH the Borrower's Responsibility and Liability and the Release of Liability Statements. The person who is the responsible party for this loan should sign these statements.

    BORROWER'S REPONSIBILITY AND LIABILITY




    RELEASE OF LIABILITY

    I agree to indemnify and hold harmless the Illinois Assistive Technology Program and any and all employees, agent or representatives of same, from damages to property or injuries (including death) to myself, and/or any other person, and any other losses, damages, expenses, claims, demands, suits and actions by any party against, the Illinois Assistive Technology Program and any and all employees, agent or representatives of same, in connection with loan(s) from the Illinois Assistive Technology Program.