Regional Equipment Library Service Request

Equipment Center
Service Requests
Service Request Form
Student Name:Date of Request:
District: School:
Grade Level:Case Manager:
Person Referring:Phone:
Is the student currently on an IEP?   Yes   No
Tasks student needs to perform (Reason for request):
Environment for AT (classroom, home, multiple rooms, etc):
What area of AT are you looking for? (Check all that apply):
  Augmentative Communication, Speech & Language Technology
  Visually Impaired Technology
  Hearing Impaired Technology
  Switches, Software, Computer Peripheral Devices
Other comments:
Approval Information - Select Authorized District Representative

Authorized District Representative (Administrator):