Device Loan Request Form

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

Contact information for the family

Please provide contact information for the family. This is the adult borrower who will be responsible for the technology.
The device will be shipped via UPS with a signature required for delivery. Is the above address the preferred shipping address?
Please include any additional information that would help with delivery.
Include your relationship to the family, first and last name, phone number, and email address.

Child Information

Please include Name, Phone, Email , and CFC number.

Device Loan Information

Borrower will be contacted regularly to check in about device and its performance.
The borrower is responsible for the proper handling, storage, use, care, maintenance, and return of the device to the Early Intervention Clearinghouse. Device will be returned to the Early Intervention Clearinghouse on or before the due date (or device can be renewed if it is still being used in EI). Please contact the Clearinghouse (877-275-3227) if:
  • the device is lost or damaged or stolen
  • If contact information for the family changes
  • If the device is not working
  • If the family pauses / discontinues / transitions out of EI
  • I will return the tech loan equipment within two weeks of when my child exits the early intervention program.
  • When technology is returned, all files (including pictures and videos), programs, and other data stored on the device will be deleted by the Clearinghouse.
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.

Complete your form

reCAPTCHA is required.