2016 EXTENDED SCHOOL YEAR AND SUMMER SERVICES INFORMATION WORKSHEET EQUIPMENT TRANSFER (DUE DATE MAY 13, 2016) – Complete this page needed equipment is not available at the assigned ESY / summer school site and is required for a student(s) to access ESY if / Summer Services. Equipment transfer(s) must be coordinated with the receiving school(s) in collaboration with ESE Service Center and District Office. EQUIPMENT THAT NEEDS TO PROPERTY NUMBER OF STUDENTS DESCRIPTION OF EQUIPMENT BE TRANSFERED* CONTROL NUMBER REQUIRING THIS EQUIPMENT Changing Table Lift Privacy Screen Adaptive Chair Adaptive Toilet Adaptive Toilet Seat Adaptive Feeding Equipment Prone Stationary Stander Supine Stationary Stander Positioning Mat Other MUST BE COMPLETED FOR TRANSFER REQUESTS LOCATION OF EQUIPMENT IN THE PICK-UP LOCATION PICK-UP LOCATION DROP -OFF DROP-OFF CONTACT BUILDING* SCHOOL NAME AND CONTACT NAME SCHOOL NAME AND NAME AND PHONE LOCATION # AND PHONE LOCATION #
2016 EXTENDED SCHOOL YEAR AND SUMMER SERVICES INFORMATION WORKSHEET EQUIPMENT TRANSFER (DUE DATE – MAY 13, 2016) Complete this page if needed equipment is not available at the assigned ESY / summer school site and is required for a student(s) to access ESY / Summer Services. Equipment transfer(s) must be coordinated with the receiving school(s) in collaboration with ESE Service Center and District Office. EQUIPMENT THAT NEEDS TO BE TRANSFERED* DESCRIPTION OF EQUIPMENT PROPERTY CONTROL NUMBER NUMBER OF STUDENTS REQUIRING THIS EQUIPMENT Changing Table Lift Privacy Screen Adaptive Chair Adaptive Toilet Adaptive Toilet Seat Adaptive Feeding Equipment Prone Stationary Stander Supine Stationary Stander Positioning Mat Other MUST BE COMPLETED FOR TRANSFER REQUESTS LOCATION OF EQUIPMENT IN THE BUILDING* PICK-UP LOCATION SCHOOL NAME AND LOCATION # PICK-UP LOCATION CONTACT NAME AND PHONE DROP -OFF SCHOOL NAME AND LOCATION # DROP-OFF CONTACT NAME AND PHONE
ESY_info_worksheet16.docx