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AT Lending Library Device Request

Please complete the form below. Required fields marked with an asterisk *

Full Name of Person Completing Request (First, Last) *

Answer required for "Full Name of Person Completing Request (First, Last) "

Email Address*

Answer required for "Email Address"

School District*

Answer required for "School District"

Role of Person Completing Request*

Answer required for "Role of Person Completing Request"

Full Name of Student (First, Last)*

Answer required for "Full Name of Student (First, Last)"

I certify that my student is eligible to receive and will benefit from a video magnifier.*

Answer required for "I certify that my student is eligible to receive and will benefit from a video magnifier."

Yes

What sorts of tasks will this student use the video magnifier for?*

Answer required for "What sorts of tasks will this student use the video magnifier for?"

Upload FVLMA or AT evaluation documentation that recommends video magnification*

Answer required for "Upload FVLMA or AT evaluation documentation that recommends video magnification"

Choose a file or drag it here.

Select the device being requested:*

See device descriptions at: https://www.tsbtigers.org/apps/pages/rcvi-lending-library

Answer required for "Select the device being requested:"

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"