Assistive Technology Loan Program

Assistive Technology Loan Program

Please select your WIHD Assistive Technology (AT) representative:

Caregiver/Parent/Service Provider Information

Please fill out the information below for the caregiver, parent or service provider.
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Borrower Type

Child/Client/Individual Information

Please fill out the information below for the child, client or individual who will be needing the equipment.
Name
Name
First
Last
Ethnicity
Parent/Guardian
Parent/Guardian
First
Last
Client/Child/Individual Address
Client/Child/Individual Address (if different than above)
Client/Child/Individual Address (if different than above)
City
State/Province
Zip/Postal
Client/Child/Individual Phone Number
Program Type

I agree to maintain the equipment in a clean working condition. The signer agrees to contact the Loan Program after the 8 week loan period to schedule an appointment to return the equipment or request an extension.
If a device borrowed includes a charging block and wire and this is not returned, I agree to pay a fee of $25.