Device Loan Request Form

Check this box if you have reviewed this contact and mailing  information for accuracy.

Yes, I understand that 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

Yes, I understand that…

• 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.

Yes, I understand that 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.