Assistive Technology Request Form

BEFORE you begin this form, make sure you have added all of the devices (up to 5 at a time) to your ‘loan cart’. If you need to add additional items, continue to browse our inventory.

Complete the form below. If you are borrowing equipment for more than one person, please complete a separate request form for EACH person.

Your Items:

Not finding what you want in our Inventory? Tell us what you are looking for:

Contact Information

Name(Required)

First Last

Address(Required)

City(Required)

State(Required)

Zip(Required)

County(Required)

Preferred Phone Number(Required)

Preferred Phone Is:(Required)

Home

Cell

Work

Secondary Phone Number

Secondary Phone Is:

Home

Cell

Work

Email(Required)

Enter Email Confirm Email

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)

Time for Date #1(Required)

Morning

Afternoon

Start Time for Date #1(Required)

End Time for Date #1(Required)

Date #2(Required)

Time for Date #2(Required)

Morning

Afternoon

Start Time for Date #2(Required)

End Time for Date #2(Required)

Date #3(Required)

Time for Date #3(Required)

Morning

Afternoon

Start Time for Date #3(Required)

End Time for Date #3(Required)

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)

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

If "other" please describe:(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)

I will pick up the items at the AzTAP office

I would like the items shipped

Name of Person who will pick up item(s)(Required)

First Last

Fax(Required)

Ship to Name(Required)

Ship to Phone(Required)

Shipping Options(Required)

NOTE: FedEx offers business and residential deliveries. Additionally, FedEx also offers a “Hold It” option where your loan shipment is held at the nearest participating FedEx location. An email address is required to use this option, since the tracking number (which you will need to pick up the shipment from the FedEx location) will be sent to you by email. For a Hold It FedEx will use the zip code of your ship to address to assign the shipment to the nearest participating location. Once your loan is shipped by us, you can use the FedEx tracking number to change the Hold It location to a different participating FedEx location of your preference.

Business

Residential

Hold It at a Fed Ex Location

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 Adobe Sign. 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

An AzTAP staff member will contact you regarding your preference for receiving and signing this agreement.

Hidden

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

Phone

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