Skip to main

COVID -19 Update

For the latest information about Mercy’s COVID-19 policies click here.  STUDENTS: To upload your vaccination documentation, click here.  

Assistive Technology Loan Agreement

Assistive Technology Loan Agreement

This form is for students with disabilities who are registered with The Office of ACCESSibility and have accommodations.


If you are looking to request a loaner laptop, DO NOT FILL OUT THIS FORM.


Please use link below

https://mercy.formstack.com/workflows/laptopreq?sso=6128f34d3ca7a&sso=6138a7127542e

First Name *
Mailing Address*
Campus*
Type of Assistive Technology you are requesting*
Checking out Assistive Technology for.... *
I would like to receive my Assistive Technology....

Loan Agreement

  • Students should inspect all equipment for any defects or other objections to the equipment before acceptance. If the student accepts delivery of the equipment, the student is presumed to have accepted the equipment in good condition and repair.
  • No other individual or entity may use the equipment for the entire time in which the equipment is on loan to the student. Equipment is not to be used for anything other than its intended purpose, as an academic accommodation, during the instructional period.
  • We reserve the right to immediately terminate this agreement and confiscate the equipment at any time.
  • Great care must be taken in preserving the equipment in good condition and any damage to said equipment will be reported in writing to Mercy College ACCESS within 48 hours of occurrence. Students shall not attempt to make any repairs without the express permission of the Mercy College ACCESS.
  • The student assumes financial responsibility for lost or damaged equipment. If the equipment is not returned by the end of the student’s final semester, returned in damaged condition, or lost, the student’s account will show an outstanding balance resulting in the charge for the equipment.
  • Non-payment will result in a hold being placed on the account which could affect the student’s inability to access grades, register, and graduate.
  • I understand that the cost to replace a lost, stolen, broken, or damaged SmartPen is $200.00.
  • I understand the cost to replace a lost, stolen, broken, or damaged recording device is $50.00. 
  • I understand the cost to replace a lost, stolen, broken, or damaged FM hearing device is $1,000.00.


  • I understand the cost to replace a lost, stolen, broken, or damaged C-Pen Reader is $300.00
Date*
Use your mouse or finger to draw your signature above
Date equipment was picked up
Date equipment was returned