Step One Regional Consultation Program
Equipment Loan Agreement Form

Equipment from the Regional Consultation Program is given to parents and/ or programs on a loan basis, for a specific amount of time. We would appreciate it if parents and programs would keep the equipment in good condition, for your use and for the next child who will use this equipment. The equipment may be loaned until it is no longer appropriate for the child to use, the parents or program replace the equipment with their own, or the child reaches three years of age.

Please fill out the following information:

Name of Equipment_________________________________________

Date Equipment was received_________________________________

Parents Name_______________________________________________

Address____________________________________________________

Phone______________________________________________________

Program Name______________________________________________

Address____________________________________________________

Phone______________________________________________________

Service Coordinator__________________________________________

Date Equipment will be returned________________________________

Parent Signature_____________________________________________

Program Director Signature____________________________________

Regional Consultation Program consultant________________________