SPED Loan of Caddo Equipment FORM

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					                                                                                Caddo Parish Schools Department of Special Education
                                             Agreement for Loan of Caddo-Owned Assistive/Adaptive Equipment
     Caddo Parish Schools will provide maintenance and repair for assistive/adaptive equipment due to ordinary wear of a piece of equipment. Per senate Bill (SB) 87, the Caddo Parish School District is not required to
                repair or replace assistive/adaptive technology devices if the device has been lost, stolen, damaged, broken, or otherwise misused while in the possession of the child, parent, or guardian.

Student Name:                                                                                                                          Date Equipment was Issued:

School Attending:                                                                                                                        Date Equipment Returned:

                                                                                 Equipment Condition                               Replacement                  Equipment Condition
                                                                                                              Current Value
      Equipment/Accessory Description                     Tag # / Serial #         at Time of Issue                                   Cost of                     at Time of Return                       Comments
                                                                                                              of Equipment
                                                                                      Check () One                                 Equipment                       Check () One
                                                                                   New           Good                                                        Good       Fair        Damaged

My child and I are requesting the loan of the above stated assistive/adaptive equipment. We acknowledge and agree to the following conditions:
           To return the assistive/adaptive equipment as requested by the authorized Caddo staff member.
           To reimburse as requested to Caddo Parish Schools the repair cost of the loaned equipment should it become damaged or broken while in the possession of my child or myself.

                                         Parent/Guardian’s Signature for acknowledgement of receipt of equipment and knowledge of maintenance and repair agreement:

Parent/Guardian Signature:                                                                                                   Parent/Guardian Name:
                                                                                                                                            (Please Print)

Address:                                                                                                                         Telephone Number:
                                                             (Street)                                                                             (Home)

                                                                                                                                 Telephone Number:
                                                         (City, State, Zip)                                                                 (Cell or Work)

SPC Authorized Staff Signature:                                                                                     Immediate Supervisor’s Initials:
(HI, VI, APE, OT, PT, Speech, ATRC, Other)

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