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Disability Resource Center

Equipment Check Out Request Form

This form will allow students to request information about available AT and equipment.

Name(Required)

Trojan ID Number(Required)

Email Address(Required)

Phone Number(Required)

Desired Equipment(Required)

Other equipment

Please indicate what equipment you're requesting. If it's not on the list it may not be available.

Please list building name, room number, station number, or any other information that will help us in properly installing the AT for you.

Agreement(Required)

I understand and agree to the following: I, the student, am responsible for returning equipment on or before the due date, in the same condition in which it was borrowed. I will be held liable for any damage or loss of equipment and will be charged by the University for repairs and/or replacement, if damage resulted from anything other than normal usage. In the event that equipment is not returned in satisfactory condition and in the time frame specified on the form, my records may be flagged to prevent future registration, obtaining transcripts or other records.

Captcha

Comments

This field is for validation purposes and should be left unchanged.

Contact
- Disability Resource Center
- DSC 103
- Phone:
  501-916-3143
  Fax:
  501-916-3068 (fax)
  Email: disability@ualr.edu
- More contact information

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