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
- Email
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 - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Start Time for Date #1 * Required

: Hours

Minutes

AM/PM AM/PM
End Time for Date #1 * Required

: Hours

Minutes

AM/PM AM/PM
Time for Date #1 * Required
- Morning
- Afternoon
Date #2 - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Start Time for Date #2 * Required

: Hours

Minutes

AM/PM AM/PM
End Time for Date #2 * Required

: Hours

Minutes

AM/PM AM/PM
Time for Date #2 * Required
- Morning
- Afternoon
Date #3 - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Start Time for Date #3 * Required

: Hours

Minutes

AM/PM AM/PM
End Time for Date #3 * Required

: Hours

Minutes

AM/PM AM/PM
Time for Date #3 * Required
- Morning
- Afternoon
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
Are you borrowing items/requesting equipment/reserving lab time as a representative of an employer, agency or organization? * Required
- No
- 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
- No
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)
Age range of person with disability who will be using 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
Our standard AzTAP Borrower Agreement is a PDF document. 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
Before the item(s) will be shipped to you, we require that you sign our written Borrower Agreement. Please tell us how you would like to receive it * Required
- By Email
- By Fax
- By US Mail
Fax * Required
Ship to Name * Required
Ship to Phone * Required
Ship to Address * Required
No PO Boxes

Street Address Address Line 2 City State ZIP Code
Is Ship to Address * Required
- Business
- Residential
Preferred mode of contact for follow up? * Required
- Phone
- Email
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Assistive Technology Request Form

Contact Information