2024-2025 Chromebook Loaner Program Check Out Form

CHROMEBOOK LOANER PROGRAM CHECK OUT FORM

Student & Parent/Guardian Information
Student Name*

First NameLast Name
Student ID #
Birth Date*

MonthDayYear
Date
Grade*
Parent/Guardian*
Relationship to Student*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #*
Parent/Guardian Email*
example@example.com

Device Information (School Admin Use Only)
Brand
Model
Serial Number
Condition at Checkout

NewExcellentGoodFairPoor
Comments on Condition
with corresponding charger
Device Checkout Date

MonthDayYear
Date
Device Return Date

MonthDayYear
Date

Chromebook Loaner Program Check Out Policy
By signing below, you acknowledge that you have read the Chromebook Loaner Program Check Out Policy and agree to be bound by its terms. You agree to return the device on the return date indicated above in the same working condition the device was in when checked out, absent normal wear and tear. You further acknowledge that you will be charged the cost of repairing or replacing the device if it is lost, stolen, or damaged.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Student Signature*

Clear
Date*

MonthDayYear
Date
Chromebook Loaner Program Check Out Policy

Each Chromebook is issued with a Chromebook charger. Each device is registered through Belmont with a Google Management License. Chromebooks that are checked out to students are the sole responsibility of the student and the parent/guardian. Students must bring back the Chromebook in the same working condition it was in when checked out, absent normal wear and tear. Lost, stolen, or damaged devices will result in the parent/guardian being charged the replacement or repair costs plus the cost of any lost software licenses. Furthermore students are required to abide by the following policies:

Each student and their parent/guardian must sign and return this form to Belmont and agree to be bound by its terms. If you need technical support with your loaned device(s) please call the school. Devices must be returned no later than the date indicated on this form. A late fine of $15 may be charged for devices that are returned late. The parent/guardian will be charged the full replacement cost of any device that is more than thirty (30) days late. Devices may only be used for students academic purposes and students must adhere to Belmont's Internet Use Policies. All online activity through the device is subject to content filtering and is monitored with Google GoGuardian, which allows staff to view online activity. Chromebooks must not be used for recreational purposes. Students are prohibited from using the Chromebook to access obscene, inappropriate, or illegal content. The use of an electronic device for any improper purpose may result in disciplinary action being taken against the student. The student and parent/guardian must comply with the manufacturer's terms of service related to the device. The student is the only individual allowed to use the device, except that the parent/guardian may assist the student in using the device for academic purposes. Devices must not be left unattended. The user is responsible for the device and its peripherals the entire time it is checked out. The student is responsible for any damage, whether intentional or accidental. The user will be charged accordingly based on the cost to repair or replace the device and any lost software licenses. The parent/guardian must immediately notify Belmont if a device is lost, stolen, or damaged. It is recommended that student users save their data to an external data source in the event the device fails. Electronic devices should be used on a flat solid surface. No device should be exposed to extreme temperatures or liquids. All devices should be securely put away when not in use.
Should be Empty:

CHROMEBOOK LOANER PROGRAM CHECK OUT FORM