Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
WIU 7 Telepresence Robot Request Form
Please complete this form to initiate a request for the IU Telepresence Lending Library. A team member will contact you after review of the information.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Student date of birth
*
MM
/
DD
/
YYYY
School District, building name, grade
*
Your answer
School district contact name
*
Your answer
School district contact email
*
Your answer
Please describe the student's need for telepresence.
*
Your answer
Anticipated date for telepresence need
MM
/
DD
/
YYYY
Additional questions/comments.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Westmoreland Intermediate Unit.
Report Abuse
Forms
