2012 13 Hat Loan Agreement Form by lizzy2008


									                                                         Lisa Lee M.A. CCC-A
                                                         HI Program Consultant

                                                         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
         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

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