Request for AT

REQUEST FOR ASSISTIVE TECHNOLOGY (AT) SERVICES

2935 Universal Court
Oshkosh WI  54904
Phone: 920-233-2372 - Fax: 920-424-4378

1.
*

Legal Name of Student:

2.
*

Gender:

Gender:

3.
*

DOB (M/D/Y):

4.
*

Grade:

5.
*

School District:

6.
*

School of Attendance:

7.
*

Name of Parent/Legal/Guardian:

8.
*

Address:

9.
*

City/State/Zip:

10.
*

Phone Number:

11.

Cell Phone #:

 

DISTRICT CONTACT INFORMATION:


 

12.
*

Type of Service Requested:

(1 required)

Type of Service Requested:

13.

If "Other" is checked above, please indicate here the type of service requested:

14.

Other Comments/Notes:

15.
*

Name of Contact Person:

16.
*

Email for Contact Person:

17.
*

Phone for Contact Person:


 

18.
*
Name of person submitting this i-form:
19.
*

Name of District Designee/Director (designated to allocate funds):

* Enter Your Email Address:

I am not a Robot

  

  • Main Office & All Mail:
  • 2935 Universal Ct
  • Oshkosh, WI 54904
  • Phone: 920-233-2372
  • Fax: 920-236-0580
  • Conference Center
  • 2300 State Road 44
  • Oshkosh, WI 54904
  • Phone: 920-233-2372
  • Fax: 920-424-3478