Assistive Technology Family Loan Agreement - MCPS Form 336-17 November 2017

Sep 16, 2026

Assistive Technology Family Loan Agreement form for Montgomery County Public Schools (MCPS) used when lending assistive technology to students with Individualized Education Programs (IEPs). The agreement collects student and guardian identification details and records each loaned item, including serial and item numbers, issuance and return dates, and accessories. It sets terms of educational-only use, restrictions on upgrades or program changes, care and prevention of misuse, participation in training, and return on demand. It also states the family’s financial responsibility after equipment leaves school property and provides signature lines for the student, parent/guardian, and MCPS staff.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Identification Information

Assistive Technology on Loan

Financial Responsibility

Signatures and Distribution

Assistive Technology Family Loan Agreement for the Loan of Assistive Technology to Students with Individualized Education Programs Office of Special Education MONTGOMERY COUNTY PUBLIC SCHOOLS Rockville, Maryland 20850 MCPS Form 336-17 November 2017 See MCPS Regulation IGT-RA, User Responsibilities for Computer Systems, Electronic Information, and Network Security and MCPS Regulation COG-RA, Personal Mobile Devices | IDENTIFICATION INFORMATION | | --- | | Student Name Student ID \# Responsible parent/guardian name Phone - - School Name--Choose One--
Name of staff member providing loan | | ASSISTIVE TECHNOLOGY ON LOAN | | 1. Item name Item Number
Barcode Serial Number Date Issued / / Date Returned / /
Accessories (describe) Date Issued / / Date Returned / /
2. Item name Item Number
Barcode Serial Number Date Issued / / Date Returned / /
Accessories (describe) Date Issued / / Date Returned / / | | TERMS OF USE | | • I agree to use all technology for Montgomery County Public Schools (MCPS) educational use only. All actions are subject to MCPS review and may be logged and archived.
• This device is being provide as a result of the student’s Individualized Education Program (IEP) . I agree not to upgrade or alter the programs in any way.
• I agree to take precautions to prevent misuse, damage, and loss and to take routine care by cleaning and protecting the equipment.
• I agree to participate in training on device set-up and use, if required.
• I agree to return device upon demand, for inventory checks or at a predetermined date. | | FINANCIAL RESPONSIBILITY | | I agree to assume financial responsibility for any and all technology, assistive technology, or equipment provided by MCPS for home use once it has left school property. Contact the Division of Business, Fiscal and Information Systems (DBFIS) at 301-279-3166 for replacement cost of equipment. | | Student Signature Date / / Parent/Guardian Signature Date / / MCPS Staff Member Signature Date / / | DISTRIBUTION: Copy 1/Assigning School Staff Member Copy 2/Principal Copy 3/DBFIS, CESC, Room 225

FAQs

What information is collected in the identification section of MCPS Form 336-17?

It collects the student name, student ID, responsible parent/guardian name and phone, school name, and the staff member providing the loan.

How does the agreement specify the terms of use for the borrowed assistive technology?

It requires educational-use only for MCPS, allows MCPS to review and log actions, restricts upgrading or altering programs, and requires precautions to prevent misuse, damage, or loss.

What financial responsibility does the family assume under this agreement?

The family agrees to assume financial responsibility for technology or assistive technology provided for home use after it leaves school property, and to contact DBFIS for replacement cost.

Sep 16, 2026

Uploaded by Sophia Brooks