TECHNOLOGY LOAN AGREEMENT

Student: __________________ Date: _____________________

Teacher _ _________________ School: ____________________
Teacher Signature: ____________________________________________________________________
Device & Serial or Tag # Accessories Software



__ Power Adapter _ USB cable __Case
__ Printer Cable _ Manual




__ Power Adapter __USB cable __Case
__ Printer Cable __ Manual




__ Power Adapter __USB cable __Case
__ Printer Cable __ Manual

To the Teacher:
1. If the IEP committee determines the student requires the use of this device at home, please send this form to the parents for their
review and signature.
2. Keep the equipment in a safe location at the school when the student is not using it.
3. When the parents return the completed and signed form, the device may then go home with the student overnight, on weekends
and during the summer.
4. Make a copy of the signed Loan Agreement and send to the AT Case Manager.
5. Keep the original signed agreement in the students Special Education file at school.
6. Report any problems with the equipment to the AT Case Manager as soon as possible.
To the Parents: The equipment described above is currently available to your child at school to assist him in his academic tasks.
The IEP committee determined it was appropriate for him to have access to this equipment at home for completion of school
assignments. We ask that you review the following conditions and, by signing, indicate your agreement.
1. I will participate in training conducted or arranged by a school staff member if required.
2. I will consistently send the device to school with my child. I understand if my child attends school without bringing the
equipment, this agreement is subject to review.
3. Neither I, nor my child, will load other software on a school computer. This includes games, music, videos, or visiting social
networking sites. Violation of these rules may result in the need to restrict the use of the device. Student
Signature_____________________________________
4. I understand my child may continue to use this equipment as long as he is enrolled in one of the Cobb County Public schools.
Otherwise, the equipment must be returned to his school at the time of withdrawal.
Parent signature____________________________________
5. Moderate securities are in place on the device while it is at school. When it is at home, the parents need to monitor access to
websites and ensure proper use of the device.
Parent Signature: ____________________________________________Date: ____________________