MEDIA CENTER _ LAPTOP CHECK-OUT FORM Fall 2022-Sum 2023

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

FALL 22 -SUMMER 23

Technology Equipment MUST be returned by:

Laptop Date/Time Checked - Out - (Fall 22, Sprg 23 & Summer 23)

Laptop Date/Time In - Fall 22, Spring 23, & Summer 23)

Laptop Renewal Spring 23

Laptop Renewal Summer 23

Student Name*

First Name

Last Name

Student ID#*

Home Address & Apt # (If applicable)*

Address Line 1

Address Line 2

City

State

ZIP Code

Personal Email*

Delgado Email*

Personal Cell Phone*

Emergency Phone (Must be a different ph# )*

Date of Birth*

What Device are you requesting*

Laptop Hotspot Both

LAPTOP PROGRAM # (DOARS OR TITLE III)

State Tag#

Bretford Pick-Up Code & Date

Library Laptop Tag #

Library Power cord tag#

LAPTOP PASSWORD

HOTSPOT T-MOBILE 5G PH#

HOTSPOT T-MOBILE 5G IMEI #

Library Hotspot Tag#

Library Hotspot Powercord Tag#

Hotspot Date/Time Check -Out Fall 22

Hotspot Date/Time - Check -In

Hotspot Date/Time Check -Out - Spring 23

Hotspot Date/Time - Check -In - Spring 23

Hotspot Date/Time - Check -Out - Summer 23

HotspotDate/Time - Check -In - Summer 23

Verified

YES NO

Notes:

Check all that apply (Note: Not all criteria needed for loan program eligibility.)*

I am currently enrolled in a degree seeking program I am currently enrolled for the current/upcoming semester for at least 6 credit hours I have NO HOLDS on my student account

Please note that all of the above will be verified by the office of Instructional Technology, Support, and Professional Development

borrower...

agrees the laptop and all accessories are the property of Delgado Community College.

agrees not to deface or destroy this property in any way.

agrees that the use of the laptop is for educational purposes to complete Delgado courses/coursework.

agrees to protect equipment from theft and/or damage.

agrees to be responsible, in the event, we are mandated to evacuate, due to a hurricane or storm, the Laptop and/or Hotspot must stay in your possession at all times.

agrees to notify the Distance Learning and Office of Instructional Technology if the equipment is damaged or malfunctioning.

agrees to notify Distance Learning and Instructional Technology and Delgado Community College Police Department in writing if the equipment is damaged beyond repair, lost, or stolen.

understands that the College will investigate the damage to or loss of the equipment and will cooperate in the investigation.

agrees to pay all repair/replacement costs resulting from damage or loss of the laptop while it is checked out in their name. (excluding normal wear and tear)

agrees that the laptop must be returned at the end of the academic semester on the last day of final exams

understands that late fees will be applied if laptop is turned in after due date .

agrees to return the laptop upon withdrawing from the College or the end of the academic semester.

agrees to return the laptop at any time requested by Delgado Community College

agrees to use the equipment safely.

agrees that inappropriate material (of a violent, sexual or political nature) on the machine may result in a student losing their right to use equipment.

agrees they will not use the equipment for the purpose of personal profit making or for commercial activities.

agrees they will use the equipment including software, email and the Internet is conditional upon compliance with all DCC policies, procedures and guidelines, including Sexual Harassment Policy & Grievance Procedures and Equal Opportunity Policy as well as Louisiana state law.

agrees not to make use of, or copy, software contrary to the provisions of any agreement entered into by the College.

agrees not to download or install any software that is not directly related to academic work.

Replacement Cost: If technology equipment is not returned 30 days after due date, equipment will be considered lost and all replacement fees will apply to your student account.

Laptop computer (Replacement cost: $966.00) Late Fee: .20 per day / Maximum $20.

Power cord or AC power pack (Replacement cost: $60.00) Late Fee: .20 per day / Maximum $20

T-Mobile 5G Hotspot Phone (Replacement Cost: $250.00) Late Fee: .20 per day/ Maximum $20

T-Mobile 5G Hotspot Power cord (Replacement Cost: $25.00) Late Fee: .20 per day/ Maximum $20

Students who are graduating will be charged a replacement cost prior to graduation day. Owing fees at the time of graduation may delay receipt of physical diploma and future transcript requests.

By clicking below, you agree that you have read, understand, and agree with all borrower obligations, as well as, understand the replacement and late fees associated with borrowing the technology from Delgado Community College*

I agree I do not agree

Student Signature*

[clear]

Use your mouse or finger to draw your signature above

Date/Time

Rating

Radiologic Technology Program DOCUMENTATION OF OBSERVATION

Start Date of Observation*

End Date of Observation*

Facility*

Supervising Radiographer*

Facility or Radiographer Phone Number*

Supervising Radiographer Email*

Volunteer Hours*

Yes No

Paid Hours*

Yes No

Total of Number of Days Spent Observing*

Total Hours*

Type of Facility*

Hospital Clinic Doctors Office

Hospital Name

Clinic Name

Doctors Office Name