Student Equipment Checkout Agreement Form (For On Campus Use Only) Date: _________ Last Name: ______________ First Name: ______________ VID#:_____________ Phone number: ________________ *Standard text messages rate will applied. □ Valencia picture ID verified A. Guidelines and Responsibilities: • Tablets are available to currently enrolled and eligible Valencia College students upon display of valid Valencia identification only. Tablets are not available for checkout to reciprocal borrowers. • Maximum 4-hour checkout, no renewals or overnight loans are allowed. One tablet maximum per patron. The equipment and all accessories must be returned when due to the location from where the equipment was borrowed. • You are responsible and financially liable for this device and peripherals while they are checked out to you. The device must be returned in the same condition in which you receive it. While using equipment on campus, do not leave it unattended. If it is not returned or not returned in the same condition, you agree to reimburse Valencia for the loss of, or damage to, any equipment checked out to you. When said equipment is returned to the department, a signature of the person accepting the equipment is to be obtained on this form, duly dated. Otherwise, you are still not released from responsibility for said equipment. Charges will include replacement or repair costs and shipping costs. Current estimated replacement fee is per item as follows: $500 for iPad, $39 for case, $13 for bag, $29 for charger and USB cable, $59 for Bluetooth case, $29 for av cable, and $39 for 10W power cable. $139 for Kindle, $17 for case, $500 for Samsung Galaxy, $39 for case. $250 for Nook, $30 for case. • Do not delete or load any apps or other software. To submit a request to have apps added, please see the Circulation staff. Report all loss, damage or malfunctions to Circulation staff immediately. B. Agreement: • I hereby accept said equipment in good working condition, with all of the accessories as outlined below, and I promise to use said equipment in a responsible, proper, and safe manner as intended for academic pursuits. I shall comply with all applicable federal, state and local laws and Valencia policies applicable to my use of the equipment. • I agree to assume full responsibility and financial liability for any tablet and peripherals checked out by me to my account, and assume responsibility to ensure the equipment is secure from loss or theft and is used in such a manner as to limit damage to normal wear and tear while in my possession. • I am responsible (financial and otherwise) for the replacement, repair, and return of said equipment if it is lost, stolen, damaged, or otherwise misplaced or diminished operationally. • I promise to keep said equipment under my control at all times, not to leave Valencia property with it, and not to release it to, or otherwise allow anyone else to use it. • I understand fines of $5 per hour or portion of an hour begin accruing as soon as the equipment is overdue and that I am responsible for paying all fines and repair/replacement costs as may accrue. After 5 days, the equipment will be declared lost and full replacement cost will be charged. I further understand a hold will be placed on my records, barring me from registering or receiving a transcript, until I pay any fines or other applicable costs in full. I agree that if Valencia College refers my account for collections, I will be responsible for attorney, court and collections costs associated with this referral. • I understand that if I fail to comply with these rules and guidelines and/or to fully and promptly pay fines or other funds due, or if I tamper with this device and/or its contents, I will be barred from future equipment checkout privileges and may be subject to campus disciplinary procedures. • I acknowledge that when I return the equipment, a staff member will verify all parts are present and that the equipment is in good working order. I will be required to remain with the staff member until this check-in is completed. During the check-in process, I may request a receipt, acknowledging the return of the equipment. I, THE UNDERSIGNED, DO HEREBY AGREE FREELY TO THE CONDITIONS AND RESTRICTIONS OF THIS DOCUMENT, AS OUTLINED ABOVE, AND DO HEREBY PROMISE TO FULFILL THEM.
Signed: _________________________________ Check out time: ________
Return time: ________
To be completed by the Circulation Department personnel Tablet #:____________ Check out time: _________ Returned time: _________
Items checked out: □ Nook □ Keyboard Case □ Kindle □ Keyboard Dock □ iPad □ Wireless Keyboard □ Power Cable □ AV Cable □ Bag □ Case Checked out by:_______
Items checked in: □ Nook □ Kindle □ iPad □ Power Cable □ Bag □ Case
□ □ □ □
Keyboard Case Keyboard Dock Wireless Keyboard AV Cable Checked in by: ______