The technology loan request form collects contact information about early intervention families requesting to borrow technology equipment from the Illinois Early Intervention Clearinghouse.

Who is completing this form?

Ask permission from the family to request technology on their behalf.

Contact information for the family

Please provide contact information for the family, including a street address AND mailing address for the caregiver/mother/father who will be responsible for the technology.

Shipping the technology

The address should be where someone is available Monday through Friday from 9 a.m. to 5 p.m.  A PO Box number cannot be used for a shipping address.
Adjust the dial to the age (in months) of the child.

Responsibilities of the borrower

Please check that you agree to the following.
I am responsible for the proper handling, storage, use, care, maintenance, and return of the device to the Early Intervention Clearinghouse. I will return the device to the Early Intervention Clearinghouse on or before the designated due date.

If the technology malfunctions, I will immediately contact the Early Intervention Clearinghouse at (877) 275-3227.
in the event I lose the device, I may be liable for its current replacement. I will immediately contact the Early Intervention Clearinghouse at (877) 275-3227.

I may be charged the full replacement fee if I do not return all of the technology I borrowed or if the technology is returned damaged. The potential costs to replace a damaged piece of technology are itemized below.
  • iPad: Repair cost determined on a case-by-case basis; $600 for full replacement
  • Hotspot: $50 for full replacement
  • iPad cover: $20 for replacement
  • AC adapter/power cord for iPad or Hotspot: $50 for replacement
I will not share the technology with any third party.

In the event that the technology is stolen despite my efforts at safekeeping, I will need to report the theft to the local law enforcement agency and provide a copy of that report to the Early Intervention Clearinghouse to prevent any replacement fees from being assigned to me.
the following activities are an unacceptable use of this technology and may be subject to legal implications:
  • Copying or distributing any proprietary software or hardware loaned through the Early Intervention Clearinghouse.
  • Violating the laws and regulations of the United States or any other nation or any state, city, province, or other local jurisdiction in any way.
  • Engaging in malicious activities.
  • Deliberately propagating any virus, worm, Trojan horse, trap-door program code, or other code or file designed to disrupt, disable, impair, or otherwise harm either the networks or systems of any individual or entity.
  • Using abusive, profane, threatening, racist, sexist, or otherwise objectionable language in either public or private messages.
  • Sending, receiving, or accessing pornographic materials.
when technology is returned, all files (including pictures and videos), programs, and other data stored on the device will be deleted.

I will not attempt to load or delete any apps or programs or attach any equipment not designed for use with the technology.

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