Student Last Name Student First Name Device ID(Serial Number)
BUENA VISTA CITY PUBLIC SCHOOLS
ELECTRONIC INFORMATION NETWORKS
INDIVIDUAL USER ELECTRONIC DEVICE CHECKOUT FORM
Buena Vista City Public Schools
2329 Chestnut Avenue Suite A, Buena Vista, VA 24416
540.261.2129
ELECTRONIC DEVICE CHECKOUT FORM
Parent Name:
Parent Email Adress:
Parent Phone Number:
Device Type: Chromebook with Protective Cover and T-Mobile Hotspot if Needed
Device Value: $239.00
Protective Cover Value: $29.95
T-Mobile Hotspot Value: $89.00
Chromebook Serial Number:
Hot Spot Serial Number:
This computer agreement is to signify that the above named student parent/guardian is fully responsible for maintaining this device. Prior to student checkout, this form must be signed by both the student and the student’s parent or guardian and returned to the school office.
It is agreed that Buena Vista City Public Schools is not responsible for any loss or damage done to the device while in possession of the student. If loss or damage occurs, the student and parent/guardian are responsible for the repair or replacement of the device.
I understand and agree to these device use guidelines and authorize my student to complete the Device Checkout section on this form in order to check out the device for the school year:
Parent Signature:
Date:
I have attended live or online and/or watched the recording of the Chromebook Remote Learning Orientation Video presented by Buena Vista City Public Schools and understand that I will be receiving a Chromebook for academic use both on campus and at home. I have read, agree to, and will abide by the BVCPS Acceptable Use Policy and the BVCPS Technology Use Guidelines. These documents are posted on our division website under the “Parent” portal for your full review.
I understand that all use of this device is my responsibility while it is checked out to me or in my possession.
Student Initials:
Please record all damage or major wear/use marks on the device prior to checkout.
Device Checkout Condition:
(Please list the condition of the device and any accessories - power cord, keyboard, protective cast and note any deficiencies.)
Security Measure