AzTAP Assistive Technology Request Form - AzTAP AT Demo & Loan Program

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Contact Information

Name(Required)

First Last

Address(Required)

City(Required)

State(Required)

County(Required)

Zip(Required)

Preferred Phone Number(Required)

Preferred Phone Is:(Required)

Home

Cell

Work

Secondary Phone Number

Secondary Phone Is:

Home

Cell

Work

Email(Required)

What is the best way to contact you if we have questions or need more information about your request(Required)

Phone

Your Request:(Required)

I’d like information about this assistive technology

I’d like a demonstration of this assistive technology

I want to borrow this assistive technology

Assistive Technology Professional – Reserve Equipment & Schedule AT Lab Time

Please provide several dates/times that you would be available for an assistive technology demonstration

Preferred Dates/Times

Please provide several dates and time ranges that you would prefer to Reserve Equipment & Schedule AT Lab Time.

AzTAP requests 2 full business days prior notice to reserve equipment and the lab. If the lab is booked, the equipment requested is not available or if more time is needed to prepare your request AzTAP staff will contact you.

Date #1(Required)

YYYY

Time for Date #1(Required)

Morning

Afternoon

Start Time for Date #1(Required)

Hours

Minutes

AM/PM

End Time for Date #1(Required)

Hours

Minutes

AM/PM

Date #2(Required)

YYYY

Time for Date #2(Required)

Morning

Afternoon

Start Time for Date #2(Required)

Hours

Minutes

AM/PM

End Time for Date #2(Required)

Hours

Minutes

AM/PM

Date #3(Required)

YYYY

Time for Date #3(Required)

Morning

Afternoon

Start Time for Date #3(Required)

Hours

Minutes

AM/PM

End Time for Date #3(Required)

Hours

Minutes

AM/PM

Are you borrowing this assistive technology for your own use or on behalf of someone else?(Required)

On Behalf of Someone Else means Not Me (e.g. using for trial with a family member who needs it, a client/patient evaluation or as a loaner for a PWD).

For my own use

On behalf of someone else

What is your relationship to the person who will be using the assistive technology?(Required)

Therapist/service provider

Family member

Friend/neighbor

Caregiver/assistant

Guardian

Employer

Other

Are you borrowing items/requesting equipment/reserving lab time as a representative of an employer, agency or organization?(Required)

Yes

Organization Name(Required)

Organization Address(Required)

Street Address Address Line 2 City State ZIP Code

First and last initials of person who will be using the device(s)(Required)

County of residence for person who will be using the device(s)(Required)

Have you previously borrowed from AzTAP(Required)

Yes

Disability of person who will be using the assistive technology (check all that are applicable)(Required)

Autism/Pervasive Developmental Delay

Chronic Health Condition

Communication/Speech

Developmental Disability

Hearing Related Disability

Learning Disability

MCS (Multiple Chemical Sensitivity)

Mental Illness

Multi-Handicapped

Neuromuscular

Orthopedic/Physical Mobility

Traumatic/Acquired Brain Injury

Vision Related Disability

Other

Not applicable (No disability)

If "other" please describe:(Required)

Age range of person who will be using/benefiting from the assistive technology.(Required)

Purpose of assistive technology loan(Required)

For assistance in decision making (for example: to be used during an evaluation or to decide on the most beneficial device for the person who needs the assistive technology

To serve as a loaner (for example: to use during repair of an existing device or while waiting for funding)

To be used as an accommodation on a short term, temporary basis (for example: borrowing a ramp for a visiting relative who uses a wheelchair)

For professional development purposes (for example: to learn more about the device; to use it during a training or presentation)

The assistive technology device is needed for:(Required)

Education

Employment

Community Living (Living as independently as possible)

Additional Comments/Needs/Requests:

What would you like to know?

Will you pick up requested item(s) at the AzTAP office or need to have it shipped via FedEx to you?(Required)

NOTE: If you live in the metro Phoenix or surrounding communities to help us reduce shipping costs, please consider selecting to pick up your loan request at our office near 3rd Avenue and Indian School Road.

I will pick up the items at the AzTAP office

I would like the items shipped

We request that whenever possible the borrower needs to be the person picking up the loan request. If this is not possible, please provide the first and last name of the person you are assigning to pick up the loan request.

Name of person who will pick up item(s) (if applicable)

First Last

Fax(Required)

Ship to Name(Required)

Ship to Phone(Required)

Shipping Options(Required)

Business

Residential

Hold It at a Fed Ex Location

FedEx offers business and residential deliveries.

Additionally, FedEx offers a “Hold It” option, allowing your loan shipment to be held at the nearest participating FedEx location based on your shipping zip code. An email address is required, as the tracking number—needed for pickup—will be sent to you. After the shipment is sent, the tracking number can be used to redirect it to another FedEx location if preferred.

For residential deliveries, AzTAP requires an adult signature and does not allow FedEx to leave shipments unattended. To avoid delivery issues, please ensure an adult is available to sign, or use a business address where the delivery can be received and held until pickup. If these options aren’t feasible, consider using the “Hold It” service described above.

Address(Required)

No PO Boxes

Street Address Address Line 2 City State ZIP Code

Preferred mode of contact for follow up communication about your loan?(Required)

Phone

Our Standard AzTAP Borrower Agreement is sent electronically via email as a PDF with Docusign. If you require an alternative format, please specify.(Required)

N/A – No alternative format is needed

Large print

Braille

Audio file

Text-Only file

Word file

The AzTAP Borrower Agreement can be signed when the loan equipment is picked up at our office. If you require an alternative format, please specify(Required)

N/A – No alternative format is needed

Large print

Braille

Audio file

Text-Only file

Word file

If an alternative format is requested an AzTAP staff member will contact you regarding your preference for receiving and signing this agreement.

If you are requesting an alternative format, please tell us how you would like to receive it. (Note: we are not able to email a Braille document).(Required)

By Email

By Fax

By US Mail

As approved ADE Loan Library borrowers, we agree to:

Assume responsibility for returning equipment by the stated due date. Usual loan period is 4 weeks. (Equipment MUST be returned in its original packing container using the prepaid shipping label in order for the library to efficiently track late, lost, or damaged equipment. This requirement is both for your protection and ours. Failure to return equipment on time may result in late charges.)

Obey software and other copyright laws. We willnot make copies of borrowed books, videos, software, and other copyrighted materials. We will remove borrowed software programs that were temporarily installed on any of our computer hard drives prior to returning the original software to the Loan Library.

Follow all stated procedures for requesting equipment from the Loan Library. Immediately notify AT Loan Library at 602-776-4659 or 800-477-9921 or at ATLoanLibrary@Nau.Edu if equipment malfunctions or ceases to operate. No attempts to repair malfunctioning equipment will be made without authorization.

Assume responsibility for the cost of repairing equipment damaged as a result of abuse, neglect, or carelessness. Reimburse the ADE Loan Library at current market value, if the equipment is lost, stolen, or damaged beyond repair.

Acknowledge that this agreement is in effect for up to one (school) year period and must be renewed annually.

Return all equipment by the end of the school year regardless of due date.

Complete the Short-Term Loan Library Feedback Form.

Have our Loan Library privileges suspended or revoked if we do not abide by these requirements.