General Information:

Semester/Session:______________________________________

Student's Name: ________________________________________

Banner ID: ____________________________________________

Telephone Number:______________________________________

Address: ______________________________________________

______________________________________________________

______________________________________________________________

Items to be checked out: 

Assistive Device

Name of the device(s): __________________________________

_____________________________________________________

Students are responsible for device(s) checked out and will be held liable if failure to return, damage, or loss occurs. I will return the device(s) to ARC at the date (end of semester) that has been specified. 

Student Signature ________________________Date __________

ARC Director Signature ____________________Date __________

Date Checked Out ____________

Date Due __________________

Date Returned _______________