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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) *

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Email Address*

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School District*

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Role of Person Completing Request*

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Full Name of Student (First, Last)*

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

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Yes

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

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Upload FVLMA or AT evaluation documentation that recommends video magnification*

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Choose a file or drag it here.

Confirmation Email

Confirmation Email *

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