HTCTU BrailleNote Loan Program

Nomination Form for California Community Colleges

Individuals interested in nominating a student to borrow a BrailleNote for one academic year should complete this form. If you are nominating more than one student, please complete an application form for each student enrolled at a California Community College. You may also read additional information about the BrailleNote device. If you have any questions, please at the High Tech Center Training Unit. Thank you for your interest!

Person nominating student:

Name:		Position:
School:		Phone Number:
E-Mail Address:
Address 1:
Address 2:
City:
State:
Zip Code:

Student Nominee:

(please enter the student's address information below)

Student's Name:
Address 1:
Address 2:
City:
State:
Zip Code:

Student's Skills:

Please describe the student's Braille skills:

Please describe the student's screen-reader capabilities:

Student's Classes:

Please describe/list the student's current classes:

Please describe/list the student's projected next semester classes:

BrailleNote Use:

How do you envision this equipment being used?

Training:

Describe how you will provide on-going training for the student during the semester the device is on your campus.

Equipment Return:

Do you agree to return the BrailleNote device to the High Tech Center Training Unit by June 30, 2008?

Yes
No

Report:

Do you agree to write a brief report by June 30, 2008, which details the successes and difficulties encountered during the semester? This report will be sent via e-mail to Gaeir Dietrich at the High Tech Center Training Unit.

Yes
No

Renewal:

Please indicate if you are just renewing the BrailleNote:

Yes, I am renewing.
No, I am not renewing.

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