Assistive Technology Service Request



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  • Service Request
  • Service Request Form
    Student Name:Date of Request:
    District: School:
    Grade Level:Case Manager:
    Person Referring:Phone:
     
    Is the student currently on an IEP?   Yes   No
    Tasks student needs to perform (Reason for request):
    Environment for AT (classroom, home, multiple rooms, etc):
    What area of AT are you looking for? (Check all that apply):
      Augmentative Communication, Speech & Language Technology
      Visually Impaired Technology
      Hearing Impaired Technology
      Switches, Software, Computer Peripheral Devices
    Other comments:
    Approval Information - Select Authorized District Representative

    Authorized District Representative (Administrator):