Lisa Lee M.A. CCC-A HI Program Consultant firstname.lastname@example.org 1425 West Grand River Ave Howell, MI 48843 517-546-5550 x6763 HEARING ASSISTIVE TECHNOLOGY (HAT) Loan Agreement Form The HAT equipment listed below is on loan for school use only and remains the property of LESA. This equipment will be picked up prior to the end of the school year. Should the equipment need repair/replacement while in use by the student, it is the local school and/or district’s responsibility to pay for the repair if not currently under warranty coverage. Please notify the HI Program Consultant immediately of any known damage or loss, or if modifications are needed. This equipment is programmed only to be used for the individual student listed below: Student Name DOB Grade Date District Building Teacher Case Coordinator Equipment: FM/SF Make Transmitter Serial Number Make Receiver Serial Number Student Hearing Aid(s) Make Model Serial Number(s) Expectations for the school district borrowing from the HAT loan bank include: To participate in equipment training sessions and take suitable care of the equipment while in the student’s possession. Provide information on the child’s progress while utilizing the HAT equipment acknowledged in the students IEP. The school district hereby releases LESA from any and all liability concerned with the use or operation of loaned HAT equipment. I understand the expectations for this loan equipment as outlined above. Signature of Person Responsible for Equipment Date
"2012 13 Hat Loan Agreement Form"