Device Loan Request Form

COMPLETE THE FOLLOWING FOR THE PERSON REQUESTING THE EQUIPMENT

First Name (required):

Last Name (required):

Phone Number (required):

Alt. Phone Number (required):
Two Phone Numbers Must Be Provided

Place Of Employment:

Home/Work Address:

Address Line 2:

State (required): County (required):

City (required): Zip Code (required):

Fax Number:

Email Address (required):

Type of individual or entity requesting the equipment. (please select the option which best describes the capacity in which you are requesting equipment) (required)

The primary purpose for which I need (or the person I represent needs) an AT device or service is related to: (select one - required)

Education - Participating in any type of educational program

Community Living - Carrying out daily activities, participating 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

COMPLETE THE FOLLOWING FOR THE PERSON WHO WILL BE USING THE EQUIPMENT

Age:

Disability:

Race:

Do you Receive Medicaid? Yes No

Do you Receive Medicare? Yes No

Do you Receive Kidcare? Yes No

Please indicate if you receive or have received services from any divisions of the Illinois Department of Human Services. Yes No

EQUIPMENT REQUESTED

PRIMARY PURPOSE

Please select only one response which best describes the purpose in which you are requesting the equipment. (required)

OTHER REASONS

Briefly describe any other reasoning or your intended use for the items you are requesting. This section is not required but may help IATP staff find alternative items if the items you requested are not available.

SHIPPING

Address for deliver where someone is available Monday thru Friday, 9am to 5pm. 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.
Ship to a different address than the one listed above

Please enter any specific notes such as AT software you would like installed, items you would like grouped together or other specific instructions:

Please read and acknowlege 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

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.

I accept the terms of the borrowers responsibility

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.
I agree to the release of liability terms