Equipment Loan Request **Please complete this form accurately as it will be part of the loan agreement. Therapist Name (required) Name of organisation / therapy / school (required) Therapist's Email (required) Therapist's Phone number (required) Full name of client trialling device (required) Client’s parent/carer name Client’s parent/carer email Client’s parent/carer phone Ship to: (required) ClientTherapist Shipping Address (Street address please, no PO box) (required) Address 2 Suburb (required) State (required) Postcode (required) Equipment (if the required equipment is not listed please contact email@example.com) Tobii Dynavox I-13Tobii Dynavox I-16Tobii Dynavox EyeMobile 5Tobii Dynavox I-110Standalone accessory - select below How long would you like to trial the equipment for? (required) 1 week2 weeks3 weeks Please indicate if you require any additional accessories (your eye gaze loan device comes with a table stand or clamp-on mount): Headmouse NanoQuha ZonoJelly Bean Switch (with device only)Specs Switch (with device only) Please specify mount (required) Monty 3d Eyecontrol HD QSFloorstand Variolock QPNone Do you need a keyguard? (required) YesNo If yes, please refer to the appropriate list and enter the cell description and part number below: Tobii I-110 Keyguard List I have read and understand the loan terms and conditions Sign Name: Note: If you haven’t heard from us within 2 weeks from requesting the equipment trial, please contact us on firstname.lastname@example.org or 08 7120 6002. Please check junk/spam folders!