Illinois Assistive Technology Program

DEVICE LOAN REQUEST FORM

I.   Complete the following for the person requesting the equipment:

Name:
Phone Number:
Alternate Phone Number:
Place of Employment:
Street Address:
City/State/Zip:
County:
Fax:
E-Mail:

Type of Individual or Entity Requesting Equipment (please select only one response which best describes the capacity in which you are requesting the equipment):
	Individual with a Disability
	Family Member, Guardian or Authorized Representative
	Educational Organization
	Employer or Business
	Provider of Employment and/or Training Services
	Health, Allied Health, Rehabilitation Organization
	Information Technology Professional

Type the primary purpose for which I need (or the person I represent needs) an AT device or service is related to:
Education – participating in any type of educational program (If checking education, please include the following)
	ISBE Referral Number (If applicable):
		Grade Level (select one):
Elementary
Middle 
High school
		Location of Use (select one):
General education setting
Home
Multiple settings
Purpose of Device (select one):
Access/Participate in general education
Access/Participate in community or vocation program 
Access/Participate in social networking
Other (please list other purpose)
School name and address (include zip code)

Community Living – carrying out daily activities, participation in community activities, using community services, or living independently
Employment – 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
Information Technology/Telecommunications – using computers, software, web sites, telephones, office equipment, and media

Do you borrow assistive technology equipment from another source:
	Yes
	No
If Yes, please specify from where:

Please indicate if you are receiving or have received services from any divisions of the Illinois Department of Human Services:
Division of Human Capital Development Services 
                    Cash Assistance
                    Food Stamp
                    Medical Assistance Card
Division of Developmental Disabilities Services 
                    Early Intervention
                    Day Services
                    In-Home Supports
                    CILA
                    Group Home
                    ICF-DD Nursing Home
                    Other
Division of Rehabilitation Service
                    Home Services Program
                    Vocational Rehabilitation Services
                    ICRE-Wood Blind/Visually Impaired Residential Program
                    Blind/Visually Impaired Rehabilitation 
                    Older Blind Services
                    Schools for the Deaf or Visually Impaired, or ICRE-Roosevelt
                    Other
Division of Mental Health Services 
                    Community-Based Mental Health Services
                    Other

Are you Medicaid eligible
		Yes
		No	
II:  Complete this section for the person who will be using the equipment:

Age:
    0-5
    6-21
    22-65
    65+
Disability:
Race/Ethnicity:
	African-American
	Asian
	Caucasian
	Latino
	Other (please specify)

III. Equipment Requested:

Name of Item:
Name of Item:
Name of Item:

Please indicate if manuals ARE NOT required with equipment requested. 

IV. Primary Purpose (please select only one response which best describes the purpose in which you are requesting the equipment):

Assist in decision making (device trail or evaluation)
Serve as loaner during device repair or while waiting for funding
Provide an accommodation on a short-term basis
Other (please specify)

V:  Address for delivery where someone is available Monday-Friday, 9 AM to 5 PM.  Do not use a P.O. Box Number for shipping address - you must include a street reference.  If delivery is at a large facility you must specify department and/or room number.

If this address is the same as the person requesting the equipment indicate here and go to section VI. 

Full Name:
Phone Number:
Organization/Agency:
Department:
Street Address:
Apartment/Room #:
City/State/Zip:

VI. Please read and sign 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 RESPONSIBILITY AND LIABILITY
				
I/We understand and agree that I/we am/are responsible for the proper handling, storage, use, care, maintenance and return of the device(s), component(s) or accessory(ies) loaned to me/us hereunder.  

I/We shall pay all costs for shipping and return of all device(s), component(s) or accessory(ies) to the Illinois Assistive Technology Program on or before the due date indicated herein or upon written demand for the same.  

In the event that I/we lose the device(s), component(s) or accessory(ies), I/we shall be liable for the current replacement value thereof. Further, I/we shall immediately contact Illinois Assistive Technology Program at 1-800-852-5110 V/TTY.  

In the event of a theft of the device( s), component( s) or accessory(ies), I/we shall not be responsible therefore if I/we immediately report the theft to the local law enforcement agency and provide a copy of that report to the Illinois Assistive Technology Program.  

In the event that the device(s), component(s) or accessory(ies) thereto malfunction, I/we shall immediately notify the Illinois Assistive Technology Program at 1-800-852-5110 V /TTY.
I/We may be required to provide collateral or other security to the Illinois Assistive Technology Program for securing my/our obligations hereunder.  I/We shall be responsible for any and all damages or diminution in value of the device(s), component(s) and accessory(ies) beyond normal wear and tear to be determined in the sole discretion of the Illinois Assistive Technology Program.
I/We shall also remit to the Illinois Assistive Technology Program any and all insurance proceeds representing the value of any device(s), component(s) or accessory(ies) thereto provided by insurance policies covering my/our residence or its contents, including but not limited to homeowner's or renter's insurance.

I/We shall not pledge, assign, transfer or otherwise give any interest in and to the device(s), component(s) and accessory(ies) to any third party.  The Illinois Assistive Technology Program shall receive and I/we shall pay and be responsible for any and all costs associated with return of the device(s), component(s) and accessory(ies), including but not limited to costs and fees of litigation, reasonable attorney's fees and costs, repossession costs and any other costs reasonably incurred by the Illinois Assistive Technology Program.  

Venue shall lie in the Seventh Judicial Circuit, Sangamon County, Illinois, for any and all litigation regarding the device(s), component(s) or accessory(ies).

I/We understand it is illegal to copy or distribute any proprietary software or hardware loaned through the Illinois Assistive Technology Program.  Upon completion of the loan, if I/we have installed such software on my/our computer, I/we shall remove said software.

In the sole discretion of the Illinois Assistive Technology Program, my/our ability to further participate in any such programs or grants or loans from the Illinois Assistive Technology Program and all of its related programs may be suspended for a period of time or indefinitely for failure to abide by the Loan Request Form and all of its obligations, including but not limited to, failure to return the device(s), component(s) or accessory(ies) in a timely manner; failure to pay for any and all costs or fees which are the responsibility of the borrower(s); and return of any device(s), component(s) or accessory(ies) in a condition beyond normal wear and tear.

Signature of Borrower:					
Date:

Signature of Borrower:
Date:
				
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.

Signature of Borrower:
Date:

Return the completed, signed request form to Illinois Assistive Technology Program, Attn: Nikki Schultz, 701 N Walnut, Springfield, Illinois 62702.