Western Dubuque County Community School District
Student Device Check-Out Form
Guardian First and Last name: *
Primary Address: *


Primary Phone Number: *()- Ext.


Child First and Last Name: *
Child School Building: *
Grade Level for 2020-2021 School Year: *


Requesting device for virtual Learning: *
Yes  No  


Requesting a device for home isolation: *
Yes  No  


Terms and Conditions: *
Yes  No  
Guardian agrees to being held accountable for all District own devices that they have checked out for distance learning use. Users are responsible for any and all expenses if equipment is lost, stolen, or damaged in any form. All devices must be returned in working order and undamaged condition.



WD Asset Tag:
For District use only. Do Not Fill Out
WD Asset Tag 2:
For District use only. Do Not Fill Out
Routing Instructions
Please route this form to the following personnel: 1. Routing level 1 (e.g. Department Head) 2. etc.
Complete the information below to route your form. * Indicates Required Fields
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.