Assistive Technology Training Request School District * Student Name * First Name Last Name Current School Grade Training Goals What would you like the student to be able to do that he/she cannot do now? Student Details D.O.B MM DD YYYY Educational Classification Specific Learning Disability (SLD) Other Health Impairment (OHI) Emotional Disturbance (ED) Autism spectrum disorder (ASD) Hearing Impairment Intellectual Disability Multiple Disabilities Orthopedic Impairment Speech or Language Impairment Traumatic brain injury (TBI) Visual Impairment, including blindness Deaf-blindness Main Contacts Parent/ Guardian Name First Name Last Name Parent/ Guardian Relationship Mother Father Aunt Uncle Grandmother Grandfather Other Parent/ Guardian Email Parent/ Guardian Phone (###) ### #### CST Case Manager Name First Name Last Name Case Manager Email Case Manager Phone (###) ### #### Teachers General Education Teacher(s) Separate names by ";" General Education Teacher Email(s) Separate emails by ";" Special Education Teacher(s) Separate names by ";" Special Education Email(s) Separate emails by ";" Occupational Therapist Name Skip if N/A Occupational Therapist Email Skip if N/A Speech Pathologist Name Skip if N/A Speech Pathologist Email Skip if N/A School Technology Representative School Technology Representative Email Contact for scheduling Check all that apply Parent Case Manager General Education Teacher Special Education Teacher Occupational Therapist Speech Pathologist School Technology Representative Other (add notes below) Notes regarding scheduling Send progress reports to Check all that apply Parent Case Manager General Education Teacher Special Education Teacher Occupational Therapist Speech Pathologist School Technology Representative Other (add notes below) Notes regarding progress reports Contact for technical support/ errors Parent Case Manager General Education Teacher Special Education Teacher Occupational Therapist Speech Pathologist School Technology Representative Other (add notes below) Notes regarding technical support Thank you! We will be in touch with you shortly to confirm the training goals and begin scheduling.
