Assistive Technology Loan Agreement
Borrower Information
Full Name
Address
Phone Number
Email
Device Information
Device Name/Type
Model/Serial Number
Accessories Included
Condition of Equipment
Loan Details
Loan Start Date
Loan Return Date
Purpose of Loan
Terms & Conditions
Agreement
I, the undersigned, agree to the conditions outlined above and am responsible for the assistive technology device while in my possession.
Borrower's Signature
Date
Lender's Signature
Date