Q
UINCY
C
OLLEGE
|
PLYM OUTH & QUINCY CA M PUSES
FOCUSED ON TEACHING & LEARNING, ONE STUDENT AT A TIME
Quincy Campus, 1250 Hancock Street, Quincy, MA 023169 Suite 508
Plymouth Campus, 36 Cordage Park, Plymouth MA 02360 Suite 220
DISABILITY SERVICES OFFICE
Quincy CampusPete Luizzi, Phone: 617- 405-5915 FAX: 617-984-1792
Plymouth Campus - Phone: 617-984-1734 FAX: 617-984-1792
Created 07/30/14
Device Loan Program
Borrower’s Responsibility and Liability Statement
Equipment Borrowed: ____________________________________________________
Replacement Value: ______________________________________________________
I understand that I am responsible for the equipment as listed above.
If the equipment is not returned in the same condition as when it was checked out, other than standard wear, I
am responsible for paying the monetary cost of all repairs. If the equipment is not returned, I will be
responsible for the full replacement – it will be charged to my student account.
In case of theft, I will not be held responsible, as long as I immediately notify the police and Quincy College. I
must provide a copy of the police report to the Disability Services Officer at Quincy College.
If an equipment breakage or malfunction occurs, I must immediately notify Quincy College at 617-405-5919. I
will not be held responsible for equipment breakage or malfunction that occurs during normal use as long as I
report it promptly.
Failure to comply with these responsibilities will result in loss of future access to the device loan program in
addition to applicable financial responsibility.
Date Checked Out: _____________ Date Due Back _____________
Condition of Equipment When Checked Out: _________________________________
________________________________ ________________________________
Signature of borrower Staff Signature
________________________________ ________________________________
Print Name/ID no Print Name
________________________________ ________________________________
Phone Number Date
click to sign
signature
click to edit
click to sign
signature
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Q
UINCY
C
OLLEGE
|
PLYM OUTH & QUINCY CA M PUSES
FOCUSED ON TEACHING & LEARNING, ONE STUDENT AT A TIME
Quincy Campus, 1250 Hancock Street, Quincy, MA 023169 Suite 508
Plymouth Campus, 36 Cordage Park, Plymouth MA 02360 Suite 220
DISABILITY SERVICES OFFICE
Quincy CampusPete Luizzi, Phone: 617- 405-5915 FAX: 617-984-1792
Plymouth Campus - Phone: 617-984-1734 FAX: 617-984-1792
Created 07/30/14
Date Returned: ___________________
Condition of Equipment When Returned: _______________________
Release of Responsibility: _____ Yes _____ No Charges Due: ___________
________________________________ ________________________________
Signature of borrower Staff Signature
________________________________ ________________________________
Print Name/ID no Print Name
________________________________ ________________________________
Phone Number Date
Submit
click to sign
signature
click to edit
click to sign
signature
click to edit
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